In the last several years, there has been a burgeoning interest in the role of moral distress and moral injury in health care. Although scholarly work began in the 1970’s, primarily in the nursing and ethics literature, the concept has continually garnered wider audiences, eventually gaining significant (and rightful) recognition during the COVID-19 pandemic.
This column and the next will examine moral distress by clarifying the term, demonstrate how to apply the concept in consistent, practical and meaningful ways, and describe how to support colleagues who have moral distress.
Multiple scholars have described moral distress as a result of a perceived violation of one’s core values and duties, concurrent with a feeling of being constrained from taking ethically appropriate action. Having moral distress is sometimes colloquially defined as knowing the “right thing to do,” but being unable to do it. Unfortunately, this definition can lack the conceptual clarity needed to help people manage their distress. A nurse may report moral distress because an attending physician’s treatment plan fails to account for the nursing staff’s concerns about what is in the patient’s best interest. A physician may experience moral distress because their patient has chosen to decline an uncomplicated surgical treatment that could extend their life.
Moral distress, however, can easily be confused with general distress or helplessness. In the examples above, there are multiple options that could be ethically justifiable. In the second example, the patient accepting or declining surgery could be ethically justifiable as part of an adequate informed consent process. For this reason, it is critical to distinguish moral distress from moral ambiguity or moral diversity, particularly when the individual assumes they already know what is the right thing to do.1 Given the ethical standards and the preferences and values of the various moral agents, there often may be more than one “right thing to do.”
The good news is that commonly when we identify moral distress, we are actually identifying moral ambiguity or moral diversity and the need for an ethics consultation that can mediate the conflict over values. (See last month’s column for an explanation on when to ask for an ethics consultation). This process identifies the range of ethically acceptable options and provides support for the health care professional when their moral position or decision isn’t followed.
Not all moral distress is as complicated to define. Contrast the examples above with the unambiguous and unfortunately frequent moral distress felt during the COVID-19 pandemic. Some health care professionals felt that they could not adequately care for patients according to usual standards either because of resource constraints or simply because of the isolation requirements needed to safely care for patients. For example, health care professionals often had significant moral distress witnessing their patients die from COVID in isolation, without the patient’s family being able to comfort them at the bedside. There is no moral ambiguity there, just helplessness at the sometimes impossible situations.
Addressing moral distress means not just obtaining ethics consultation as needed but also dealing with the feeling of powerlessness that often accompanies it. If the original narrative with moral distress was about some health care professions attempting to free themselves from the oppression of others in medicine, more recent discussions have approached the issue similarly. A medical student might report moral distress when constrained by their residents and attendings; physicians might feel moral distress when constrained by their patient’s choices.
What is the experience of powerlessness for those in moral distress? Is it lost power or never attained power? Loss of power to act or power to influence? Is it a part of the normal helplessness many health care professionals sometimes feel when caring for patients?2 Rather than focusing on the moral ambiguity or the moral indignation that can sometimes be a part of moral distress, it can be useful to uncover and examine the power dynamics of moral distress.
A nurse or a medical student might be feeling morally distressed when a physician advocates for a treatment plan that doesn’t promote their conception of what is in the patient’s best interest. Rather than anchoring to “the right thing to do,” because there could be reasonable moral diversity leading to multiple ethically justifiable options, what if they focused on what has led to the power dynamics and what can be done about it? Did the nurses have no power in this scenario and if so, what is specifically limiting it? What specific power does the attending hold? How can medical students productively exercise any power they may have?
What can individual health care professionals do when feeling morally distressed? First, consider calling an ethics consultation. Second, anyone can and should try to recognize their current internal state – am I feeling anxious, angry, sad, or helpless? Are those feelings about me or the patient? Next, one can allow themselves to experience that distress without avoidance and take perspective on it and the situation that may have led to it. Following this model, and with time and support, health care professionals can find it easier and more productive to react mindfully to future challenges.
A significant risk of moral distress is that it can disengage health care professionals from their patients or their colleagues and divert them away from their core commitment to patients. This is not an accusation of blame, but rather an assertion that they have considerable agency, choice, and ultimately control to effect change. Health care professionals will often need support through ethics consultation, their colleagues, or their institution to help them adequately address their moral distress. That will be good for them and ultimately for their patients.
The next column will discuss the risks for moral distress affecting patient outcomes.
David J. Alfandre, MD, MSPH, is a health care ethicist and an Associate Professor in the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the VA National Center for Ethics in Health Care or the US Department of Veterans Affairs.
- Repenshek M. Moral distress: Inability to act or discomfort with moral subjectivity? Nurs Ethics. 2009;16(6):734-742. doi:10.1177/0969733009342138
- Brody H. The Healer’s Power. Yale University Press: London. 1992.