The Quiet Power of Speaking Up
A Guide to Diplomatic Defiance for Reinforcing Ethical Systems by Wendy Dean, M.D.
Last month’s article introduced a concept we called diplomatic defiance, and promised more to come. When I consider “diplomatic defiance,” it reminds me of author Jason Reynolds’ advice to, “Stand on your square.” It is the steadfast refusal to be moved off our truth - off what we know is right for ourselves and our patients. It is unapologetic, courageous, unwavering, and calm: holding our ground, without drama. (By the way, Jason Reynolds’ interviews with Sara Enni, Krista Tippett, or Brené Brown are worth your time.)
Tensions are high in many healthcare systems right now. The federal government is slashing research programs, cuts to Medicare and Medicaid loom, and staffing shortages still haven’t rebounded from the pandemic.
At a recent town hall in a large health system, frustrations boiled over after remote executives abruptly changed scheduling platforms. The shift made it harder for clinicians to simultaneously deliver both high-quality care and meet productivity demands. Local managers tried to downplay concerns, calling the daily corporate emails outlining unrealistic expectations and punitive consequences “overblown.”
Staff were silent until one clinician calmly asked:
“If that’s true, when can we expect the threatening emails to stop?”
That question was a masterclass in diplomatic defiance.
What is Defiance?
Traditionally, defiance is defined as “an act of open or bold resistance.” It is a powerful, often polarizing word conjuring images of rebellion, disruption, and willful contrariness. We associate it with toddlers or with a diagnosis like oppositional defiant disorder.
And yet, defiance may be exactly the word we need to describe a vital corrective to moral injury in healthcare.
Dr. Sunita Sah, in her book, Defy, offers an alternative definition:
“Defiance is acting in accordance with your true values when there is pressure to do otherwise.”
That space between an inciting betrayal and collapse into compromise is where defiance lives. When clinicians feel pressure to violate their ethics, they have a choice: to acquiesce, or to speak up and resist. To defy
Defiance Is a Skill, Not a Trait
The clinician at the town hall resisted - defied - by calmly questioning troublesome leadership tactics. It wasn’t loud or dramatic. It was principled and mature.
Defiance is not a personality trait. It is a learned skill, built over time, and practiced often. Here’s how:
Know your values. Acting “in accordance with your true values” starts with knowing what they are. Take the time to reflect and have clarity on your core values.
Feel the threat. Know how your body signals a values conflict – tight neck, racing heart, knot in the stomach. Recognizing those cues helps you know when to act.
Acknowledge it. Name the threat - at least to yourself. That’s when you can begin to plan your response.
Act. Practice is key. Diplomatic defiance may never feel easy, but it does get more familiar.
Rehearse short, firm statements or questions in advance.
Start in low-stakes situations.
Accept discomfort. Courage isn’t comfortable; it is being uncomfortable and acting anyway.
Practicing Defiance in Low-Stakes Moments
Being a patient can provide practice. At a recent sports medicine appointment, the medical assistant gestured for me to step on a scale. There was no clinical need to collect that number, but recording it could bolster billing. I felt the flush of adrenaline. Two values alarms sounded: Unnecessary upcoding and irrelevant data collection. I kindly, but clearly, declined. The missing weight was never a problem during the appointment, and I’d practiced resisting a values threat - standing on my square.
Why “Diplomatic”?
What about the “diplomatic” part? Defiance doesn’t need to be loud to be powerful. The most effective pushback is often calm, thoughtful, and curious. Diplomatic defiance invites reflection, not retaliation. Ideally, it creates space for others to join you, on your square, because it looks like a place of clarity and safety.
One of the simplest ways to practice this is through strategic, relentless curiosity:
“When can we expect the emails to stop?”
“How does this proposed change in practice align with our organization’s mission?”
“How can I follow both this organization’s policy and national guidance from my professional society?”
“Can you remind me of our goal for this meeting?”
A Call to Practice
Honing the skill of diplomatic defiance - knowing when and how to speak up against policies and practices that put patients or professionalism at risk - is more vital now than ever. Solidifying that skill set requires clarity of values, self-awareness, emotional regulation, and practice.
What can you do by next Tuesday?
Find a partner.
Imagine some scenarios and practice simple phrases to resist:
“Could you clarify for me . . . “
“Remind me what our goal is with . . . “
“How does this align with . . . “
“What value will this add for patients?”
Make a commitment to low-stakes practice.
Final Thoughts
We don’t need to wait for a hero. We need to become practiced advocates for ethical care. When we speak with clarity and courage, we lead others to safer ground - to the square we claimed when taking our oaths and entering our professions.