When Accountability Exceeds Agency: Executive Moral Injury and Organizational Fragility in Healthcare Leadership.

Moral injury in healthcare is most often discussed in relation to clinicians, but healthcare executives may also experience morally significant distress when they remain accountable for organizational outcomes without sufficient agency, information, trust, or voice. This commentary introduces accountability without agency as a potential pathway to executive moral injury. Drawing on scholarship on moral injury, moral distress, psychological safety, and organizational conditions, it examines how suppressed candor, routine bypassing of accountable executives, and persistent centralization of decision-making can harm leaders and weaken organizational coordination and resilience. Although evidence specific to healthcare executives remains limited, research among healthcare workers demonstrates that moral conflict can have consequences beyond occupational dissatisfaction. The commentary concludes that healthcare organizations can reduce these risks by aligning responsibility with decision rights, protecting executive voice, distributing strategic context, and developing leaders capable of exercising judgment in service of the mission.