Ethical Pragmatism in Healthcare Management: A Multidimensional Framework for Responsible Decision-Making Under Real-World Constraints

Healthcare leaders frequently make decisions under conditions of uncertainty, competing stakeholder interests, resource constraints, and changing clinical and organizational demands.Established ethical traditions provide normative guidance, while procedural approaches such as Accountability for Reasonableness emphasize transparency, relevance of reasons, opportunities for revision and appeal, and mechanisms for ensuring fair healthcare decision-making.However, executive decisions are also shaped by organizational realities, societal and institutional conditions, and consequences that may unfold across different time horizons.This paper develops a healthcare-management-specific conceptualization of Ethical Pragmatism and proposes the Ethical Pragmatism Decision Landscape (EPDL) as a multidimensional representation of executive deliberation across four interacting domains: ethical foundations, organizational realities, societal and institutional context, and temporal perspective.Whereas Accountability for Reasonableness primarily addresses the legitimacy and procedural fairness of prioritysetting decisions, the EPDL adds a structured approach for examining how ethical principles, operational feasibility, contextual pressures, stakeholder interests, and short-and long-term consequences interact in the formation and evaluation of executive decisions.Within the EPDL, Ethical Elevation is introduced as a comparative deliberative concept for examining the ethical defensibility of available options.The Most Ethically Sustainable Decision (MESD) represents the option judged most ethically defensible and practically sustainable among those reasonably available within a defined context.The framework is illustrated through applications to resource allocation, workforce planning, emergency department overcrowding, public health emergencies, strategic decision-making, governance, and health policy.Ethical Pragmatism is intended to complement rather than replace established ethical and procedural approaches by extending transparent justification and revisability into a broader multidimensional process of executive ethical deliberation.Further conceptual and empirical research is needed to examine the framework's applicability, clarify its constructs, and evaluate its potential value in healthcare executive decision-making.