Ethical dilemmas concerning decision-making within health care leadership: a systematic literature review

objective


Introduction
Relevance.Management and administration in health care is in a state of revolution based on positive transformational changes (1).The reason why health care organizations exist is to provide better care for individuals through providing shared resources for groups of people.This creates a paradox at the heart of a health care organization because serving the interests of groups sometimes encounters serving the needs of individuals.In this context, ethical dilemmas emerge that are experienced by leaders by virtue of their position in the organization (2).Today's leaders in health care are being challenged by many demands and issues.To confront these many demands, health care leaders must have the ability to make decisions based on ethics (3).Moreover, there is a need to recognize the complex interconnectivity between the decision-making, leadership, and ethical dilemma in health care management / administration context.
Originality.Literature on management, administration, or leadership has been growing rapidly, and this growing literature treats the leadership as a natural function or management role (4) and it is seen not rare more as nonformal activity (5) than formal position.When decisions concerning the financial resource allocation, division of a budget for institutional versus health care personnel needs, limited or prolonged treatment of the patients should be made and this should be balanced with the needs of customers, patients, and health care personnel, etc., not only managers or administrators but also leaders play key roles.Namely, they integrate their personality and status power within various ethical dilemmas and make decisions (6)(7)(8).In growing scientific literature concerning management, administration, and leadership in health care, the main emphasis is on ethical codes (9), ethical principles (10), ethical reasoning (11), etc.There is a lack of scientific literature in general and in health care research specifically with the focus on ethical dilemmas concerning decision-making within health care leadership by defining ethical dilemma and highlighting essential aspects to which it is attached by being integrated with decision-making and leadership.
The objective of this systematic review is to describe the research methods and research focuses on ethical dilemmas concerning decision-making within health care leadership.
The following research questions were addressed: What is the scope of studies for the topic?How is the ethical dilemma concerning decision-making within health care leadership defined?

Material and methods
Search methods.The systematic review concerns ethical dilemmas within health care management/ administration with the focus on empirical research about decision-making by leaders.
Database searches.The literature search was conducted on two electronic databases.These databases were Medline andPubMed (1998-2008).The search strategies were specific to database with the key words that reflected health care ethical dilemma, management/administration, and leadership as an integral phenomenon.The search was performed using the following integrated key words that consisted of complex words: "health care management," "health care administration," "decision-making," "health care leadership."The key words were combined using the Boolean operator AND or OR with the second keyword "ethical dilemma." A search using the main keywords yielded a large number of articles on ethical dilemmas and health care.When the search was limited to empirical studies, leadership, and decision-making only concerning ethical dilemmas, the number of articles was reduced.A total of 888 various studies were identified through the initial search.Having read the abstracts, introductions and conclusions of identified all studies, the articles that presented only health care practice without focus on ethical dilemmas and leadership within decisionmaking were excluded.In total, 73 articles were accepted for full-text reading.Having read the full-text articles, the articles that presented discussions only on ethical issues without connection to health care management/administration were excluded.Having checked the latter articles, a total of 21 empirical studies that met the inclusion criteria were identified.A summary of the characteristics of the study performed is shown in Figure .Inclusion and exclusion criteria.The following inclusion criteria were used: the full article was published in scientific peer-reviewed journals in English; the article was published between 1998 and 2008; the article content was based on empirical evidence; the articles were based on integrated approach covering health care (biomedicine, nursing) and social sciences in the articles, the ethical dilemmas were discussed in health care management/administration context with the focus on leadership.Empirical studies with the focus only on social sciences (without integration with health care or nursing) and/or only on public health care approaches were excluded.
Retrieval of references and handling.Only English text papers published in peer-reviewed journals were selected for further review.Research abstracts, perspectives, guidelines, public reports, debates, ethical forums, letters, editorials, synopses, literature notices, commentaries, viewpoints, clinical reviews, news, newsletters, book reviews, research debates, duplicate texts, and conceptual papers were excluded.Content analysis was designed to classify data by the characteristics deemed the integration of theoretical importance and methodological parameters within the systematic literature review (12)(13)(14)(15)(16) according to research questions.

Results
Ethical dilemmas within health care management/ administration with the focus on decision-making by leaders have been investigated by implementing qualitative (n=13), quantitative (n=7), and mixed (n=1) designs.In studies with the qualitative design for data collection, the semi-structured (n=9), unstructured (n=1), narrative (n=1), and focus-group (n=2) interviews were applied.For data analysis in most of the studies, the qualitative content analysis (n=7) and other analysis methods -phenomenological hermeneutics (n=3), grounded theory (n=2), and thematic modified analysis (n=1) -were applied.In all quantitative design studies, a questionnaire survey (n=7) was carried out, and for data analysis of all the studies, a descriptive analysis (n=7) was applied.The latter analysis method mentioned was integrated with other statistical analysis methods: (a) the complex statistical analysis procedures such as one-way analysis of variance, multivariable logistic regression analysis, multiple linear regression, χ² test, and inferential statistical procedures were applied in most quantitative studies (n=4); (b) the principal component and factorial analyses (n=3).In the study (n=1) with a mixed design, a quantitative data collection method such as concept mapping was applied, and for data analysis, multivariate statistical analysis was employed.
In most qualitative design studies, the study participants were physicians (executives, department heads, health care politicians) as formal leaders (n=10), and only in several qualitative studies (n=3), nurse executives as a part of mixed sample with the physicians had participated.In quantitative design studies, the study sample included nurses-executives with the following participants: nurses-practitioners, physicians-practitioners and executives (n=1); nursespractitioners, practitioners and physicians-managers, and therapists (n=1); physicians-practitioners and executives, social workers, psychologists, mental health counselors (n=1).In addition, the quantitative studies enrolled physicians-practitioners and formal leaders (department heads, clinic and hospital executives) (n=1) and with therapists-managers (n=1).In a mixed design study, the participants were health care professionals (physicians and nurses-practitioners, and executives), health care policy makers, patients and their family members, and members of social environment (n=1).

Definition of ethical dilemma concerning decision-making within health care leadership at different levels
The empirical articles, where the ethical dilemma would be defined, have not been found.However, in the content of the selected articles, the various terms were used, which were treated as adequate to the term "ethical dilemma."The context of the ethical dilemma was also highlighted.According to reviewed selected articles, it could be summarized that decision-making concerning ethical dilemmas within health care leadership is implemented at three levels, such as 1) political and local interface, 2) national, and 3) institutional.The division of ethical dilemmas into mentioned levels is one of the results of the systematic review, and it was influenced by methodological decisions presented in the articles: the studies were performed with study participants from the three

FULL-TEXT ARTICLES REVIEWED AND INCLUDED (n=21)
Exclusion criteria: 1) nonempirical papers; 2) synopses, commentaries, etc.; 3) only social and/or public health approach Ethical dilemmas concerning decision-making within health care leadership mentioned levels, and ethical dilemmas concerning decision-making within health care were connected to various aspects at a specific level (see Table ).
• Political and local interface level.Decisions are made by health care politicians from municipalities (rural, urban) or government with the focus on local communities or regions (17,18), i.e., by local government.The politics is contextual and needs to be explained in local context when the actual decisions should be made (19)(20)(21).• National level.The decision-makers/leaders of the national level (from various parts of one country or several institutions with the inclusion of various professionals that are specific for the country health care system) are concentrated on implementation of general health care management (22) and administration (23) principles in national context with the focus on the needs of country inhabitants (24,25).This level integrates expertise and system.• Institutional level.The formal leaders of institutions, such as general management (20,(26)(27)(28) or hospital/health care center administration, or a formal team leader as a head of the department make decisions (10,32,33).(17) gatekeepers, and trade-offs are concerned about economic issues that are treated as health outcomes for the patient within the health care system.

Husain et al., 2007 (18)
Ethical dilemma is the result of resource allocation within health care sector, where political, ethical, and technical judgments interplay.
Sarikaya and Erbaydar, Ethical dilemma is the gap between professional obligations and possibilities of health care professionals, 2007 (20) and efficacy of health care system.

Liegeois and Van
Ethical dilemma is the continuous balancing with the need to make decisions on the setting aside budgetary Audedhove, 2005 (21) resources versus the provision of further financial incentives for community care.

Chipp et al., 2008 (22)
Ethical dilemma is the ethical difficulty that arises concerning principles of patient's confidentiality, which emerge for health care providers in rural and small urban communities.Berney et al., 2005 (23) Ethical dilemma is an outcome of medical choices based on problem-solving (identifying the single and most correct solution to a problem, which requires expertise in patient's limited role concerning his/her involvement) and decision-making (making a choice from a number of possible alternatives by involving trade-offs).

Hurst et al., 2005 (24)
Ethical dilemma means the concern about specific interactions that are actual only for national/country context, e.g., interactions between ethical consultants and physicians.
Warner and Monaghan-Ethical dilemma is the concern about society access to health care resources by balancing between the lack Geernaert, 2005 (25) of available health care resources and responsibility for quality care.

Institutional level
Mamhidir et al., Ethical dilemma means being in ethically challenging or difficult situations where the physicians-and 2007 (19) nurses-leaders should balance between loyalty to their job, which forces them to make reductions, and own conviction that they implement their mission concerning provision of good health care.Wienand et al., 2007 (26) Ethical dilemma is balancing between several decisions concerning the following organizational climate components: performance assessment and reward systems, leadership style in the unit, job satisfaction, organizational communication, perceived quality of care, team spirit, as well as training and development Torjuul et al., 2004 (30) Ethical dilemma is integral and include patient's autonomy, justice, and conflict issues among parties at the same time when the decision should be made concerning a patient.
Saad Bin Saed, 1999 (32) Ethical dilemma as a consequence of the emerged "ethical concern" or "ethical issue" that stipulates to make decisions by leaders-specialists representing an institution or executives who monitor implementation of medical practice standards at the institution.
is focused only on patients as vulnerable people (21).Politicians as human beings experience "double" ethical dilemma -as politicians being in high positions and as human beings (20,34).Effectiveness and efficiency tend to be the primary concern of policy makers and therefore to dominate their perspective on good care (17,18,35).Ethical dilemma at interface level of political and local levels is named differently: • Ethical dilemma as continuous balancing is experienced because of increased care needs together with declining budgets that contribute to ethical challenges in health care system (24,36).It is associated with a lack of good care (17,20), weaknesses in medical support (17), dissimilar focuses between caring systems, justness in the distribution of care and deficient information (18,21).• Ethical dilemma as a result of resource allocation is concerned about setting aside budgetary resources versus the provision of further financial incentives for community care (17,18,20,21).• Ethical dilemma as a gap between professional obligations and possibilities is perceived through the most critical issue in health care system and is related to the surveillance system (20, 37).• Ethical dilemma as an ethically controversial situation is experienced through physician's obligation to inform the patients (17,35).
The results of literature review revealed that ethical dilemmas concerning decision-making within health care leadership at an interface level of political and local levels are related to the following aspects: economic concern about country's health care system (17,19), requirements for quality care in care settings and medical support (19), standardized system for quality care assessment/evaluation in country's health care institutions (21), objective acknowledgment of society about local health care situation (18,20).
National level.The national level is mostly concentrated on professional activities of physicians (23,24).A physician becomes as a representative of health care system, as a specialist and as an expert -a professional.Besides, he/she is a person-professional who should take responsibility for health care decisions concerning patients (22,25).Ethical dilemma at national level is named variously: • Ethical dilemma as a concern about specific interactions among specialists means that every country has its health system, which includes general and specific aspects (38).These integrate the classification of specialists and national infrastructure of health care system in a country (23,24).• Ethical dilemma is treated as ethical difficulty in national context with the focus on rural or small communities (that are not rare ethnic) concerning principles of patient's confidentiality.This difficulty emerges for health care providers in rural and small urban communities (22,39).
• Ethical dilemma as an outcome of medical choices is attached to current dominant ideology of health care in Western countries.This idea supports the active participation of patients in decision-making (23,40), but this is less accepted in other countries, for example, in Japan, where physician's paternalism remains dominant (35).• Ethical dilemma as a concern about society's access to health care resources is related to three aspects: access to health care, patient-caregiver relationship, and reactions to stigmatizing illnesses (24,25).It appears that overlapping between personal and professional roles is perceived and handled differently and, perhaps, is treated in rural than urban areas more adaptively.The systematic literature review illuminated that ethical dilemmas concerning decision-making within health care leadership at national level is connected to the following aspects: society's viewpoints concerning competence of health care professionals ( 24), (non)formal interactions between health care providers and rural communities (22), professional authority of health care specialists in society within their interactions with the patients (23), and patients' access to health care (25).
Institutional level.The ethical dilemma at institutional level is integral.It includes issues and conflicts among several parties such as health care personnel, patients and their relatives, organization and its administration.In such context, the decision should be made by leaders concerning patients' wellness and quality of care (29,30).An ethical dilemma at institutional level is named differently: • Ethically difficult or ethically challenging situation is experienced when physicians-leaders and nursesleaders should make decisions that would have negative consequences for care through striving to satisfy the society and institutional expectations (19,41).• The balancing between several decisions as the ethical dilemma emerges in the context of organizational climate and loyalty organizational values (26,29).• Ethical concern or ethical issue is perceived as an ethical dilemma concerning physician's inattentiveness to medical needs of his/her patients and monitoring of implementation of accepted stan-dards concerning medical practice by all medical personnel (32).• The consequence of ethical issue or concern as an ethical dilemma is experienced through four types of interactions (29, 30): 1) physician-other physician colleague is balancing between autonomous personal professional expertise-based decisions that are connected to physician's competence and his/her acting according to recommendations of other colleague physicians; 2) physician-community interaction means the increasing expectations and pressure from patients in order to make more despite limited and unequally distributed resources; 3) interaction between a physician and hospital executives is related to patients' diagnoses and consequences in which they are coded to determine the amount of government reimbursement, which the hospital receives; 4) physician-health care system interaction means that the physician experiences a dilemma by balancing between himself/ herself as a professional and human being in the context of existing problems within health care system (e.g., long waiting lists for specialized treatment and surgeries).

Limitations
This systematic review has some limitations.The first is related to complicated multidisciplinary focus of the systematic review, which integrates four concepts such as "ethical dilemma," "health care leadership," "decision-making," and "health care mana-gement/administration," that are not studied in a complex in any of the reviewed studies and are presented in the articles with the focus on one of the mentioned concepts explaining it in a specific context.Such a situation encouraged us as the article authors to find out the way how to highlight all the mentioned four concepts in every analyzed study that was limited to three levels.The second is related to scope of the scientific articles analyzed.This has to do with the different sites, chosen study samples, where physicians are most often the participants of the studies, and the analyzed "ethical dilemmas" most often are concentrated on ethical issues concerning physician's position such as a leader, manager, or executive.Other professionals, for example, nurses, social workers, physiotherapists, clinical psychologists had participated only in several studies.In addition, the quotes of participants in a sample concerning their professional status are very different.The methodologies of studies are traditional and do not differ at different levels such as political and local interface, national, and institutional.All these aspects limit the possibilities of comparability between sites, sample participants according their professional status, and research methodologies applied.The third limitation is related to exclusion of the articles that represent the studies with only social science and public health approach though the "health care" context integrates both.The fourth limitation is related to decision to use two core keywords such as "ethical dilemma" and "health care" (by adding management or administration) without focusing specifically on allied terms such as "nursing," "nursing care," or "biomedicine" (management or administration).The fifth limitation of this systematic review is that it covered only studies in the English language.

Discussion
To our knowledge, this is the first systematic literature review to document ethical dilemmas concerning decision-making within health care leadership.Five conceptual/descriptive (3,6,34,42,43) reviews and one systematic review (9) related to ethical dilemmas of management/administration sphere concerning decision-making by formal leaders within health care were done.However, they were limited to specific contexts, such as health care research, health care practice and medicine (6), infectious disease outbreaks (34), communication and information issues (9), managed care (42), end-of-life situation of a patient (43), and evidence-based leadership (3).
No study to date has defined the ethical dilemmas concerning decision-making by leaders within health care.Some authors used directly the term "ethical dilemma" (21,29,30,33,43).In most cases (according to analyses of this systematic literature review study) for discussions about ethical dilemmas concerning management/administration within health care, the following terms were used: "conflict of interest," "ethical challenge" (6,19,43), "ethically difficult situations" (19), "ethical concern" (32), "action ethical dilemma" (29), "ethical issue" (27,32), "ethical conflict" (42), "ethical difficulty" (22,24), "ethically controversial situation" (17), "ethical considerations" (25), "ethical leadership" (2).By using these different terms (instead of the term "ethical dilemma"), the authors discuss about ethical dilemmas by broadening the understanding about it, and the term "ethical dilemma" could be found in the text.Nevertheless, no article has defined ethical dilemmas concerning leadership or management/administration within health care.In all the studies analyzed, the ethical dilemmas are contextualized concerning the country such as Denmark (17), Italy ( , United States of America (22,24,25,30), or it is attached to a very specific problem, concern, or issue, e.g., influenza pandemic (27), infectious disease outbreak (34), decisions to limit lifesustaining treatment in intensive care units (10,31), occupational therapy and physical therapy (33), quality of end-of-life care (43), resource allocation within national AIDS control program (18), bedside rationing (17), rationing of health care (23), etc.The authors of analyzed articles discuss the problems concerning ethics and attach them to decisions, and point them out as possible ethical dilemmas that were met by leaders as decision makers.
According to the analyzed studies, there is no empirical research with the complex focus on integration among ethical dilemma, leadership, and decision-making.In order to broaden the systematic literature review and deepen the understanding about this complex research focus, the terms "health care management" and "health care administration" were added.Such broadening established premises to illuminate that in health care management/administration, ethical dilemmas are concerned with the decision-making, but not between two choices as it is usually described in the literature about ethical dilemmas in health care practice (7,8).In such a context, the leaders should make decisions by balancing among several choices, e.g., three (6,27,30), four (26), six (29), and deciding about one.But the studies analyzed do not highlight this fact, and in most studies, the discussions are concerned about interactions among health care personnel (30) or between health care professionals and patients (29), ethical reasoning of leaders (11), ethical leadership (2), leadership in team-working (10).These examples point out the lack of research focus on the definitions of ethical dilemmas, specifications concerning the decision-makers/leaders at different levels in order to highlight the specific nuances of ethical dilemmas.By reading the analyzed studies, it seems that almost all ethical dilemmas of formal leaders are concerned only about resource allocation (19,21) or budgetary issues at institutions (28) or municipalities (22,25).Such understanding narrows the concept of an ethical dilemma concerning leadership as well as management/administration within health care and leaves the readers with the very simple perceptions with the only focus on utilitarian ethics, efficiency, effectiveness, or efficacy that could be counted by ignoring the humanistic aspect.This fact could be argued that the humanistic aspect is illuminated through qualitative studies.Despite the fact that qualitative research by its methodological parameters is attached to ethical dilemma, decision-making by leaders is narrowed into personal perceptions or reasoning about the difficult complex situations that are met in a specific context, for example, critical care (10,19,28).This does not lead to the definition of ethical dilemmas concerning decision-making within health care leadership.
Concerning the methodological decisions in qualitative studies, the core method for data collection is a semistructured interview (10,19,28,31), and for data analysis, the qualitative content analysis is applied (18,20).Not rare, the samples of qualitative research include only physicians, and if in some studies, research participants are representatives also of other health care professions, the balance between those subsamples is not kept.The results are presented with no specification concerning every professional activity that makes difficult to understand the specific nuances of ethical dilemmas concerning decision-making within health care leadership, especially with the focus on various professionals' activities.Quantitative studies mostly are based on questionnaire surveys, and the strategy of sampling usually is not explained, for example, why the sample consists of one-third of physicians-practitioners and two-thirds of physicians' executives (32), but the results are compared.Does this comparability help to understand the decisionmaking concerning ethical dilemmas as valid?Is it valued from the scientific point of view?The near similar situation is with the study by Wienand et al. (26), where the sample consisted of thousands of participants who represent the various professions such as physicians, scientists, management employees, nurses, therapists, laboratory and radiology technicians-leaders.However, their distribution in the sample was unequal, and results were presented by generalizing the answers of all the professionals.This context points up that studies lack specification according to professional qualification in leadership of those professionals within ethical dilemma situation concerning health care management/administration context.

Conclusions
In the view of the results of this systematic literature review, it can be suggested that research on ethical dilemmas within health care leadership, management, and administration should integrate data about levels at which the ethical dilemmas occur.In addition, it is important to investigate ethical dilemmas not only as a separate, but also as a complex phenomenon, which is attached to decision-making and specific nuances of health care management/administration context.
In the scientific literature, there is a lack of focus on ethical dilemmas concerning decision-making within health care leadership; nevertheless, this complex phenomenon has come to occupy the forefront of the discourse pertaining to areas of health care management, administration, leadership, and professional ethics in health care and medicine.Generality and inaccuracy of the notion of "ethical dilemma concerning decision-making within health care management" creates the limitations in research and practice of health care management, administration, and leadership.The boundary of this problem encompasses the domains of the decision-makers as leaders and those involved in the conduct of health care management, administration, and leadership research.In addition, it includes those who are responsible for decisionmaking at various levels within health care.The research problem, which had been presented in this article and solved through the systematic literature review, requires the extensive scientific discussions, and empirical research how to best address the ethical dilemmas concerning decision-making within health care leadership at institutional, national, and political levels, this issue engenders, remains in evolution.

Fig.
Fig. Search flow for ethical dilemmas concerning decision-making within health care leadership

Table .
Explanations of ethical dilemmas concerning decision-making within health care leadership at the three levels: institutional, political and local interface, and national Authors Explanation of ethical dilemma Political and local interface level Lauridsen et al., Ethical dilemma is an ethically controversial situation, when care professionals should act as economic 2008