Ethical Issues in Medicine Moral distress can disengage health care professionals from their patients or their colleagues

BY DAVID J. ALFANDRE, MD, MSPH

In the last few years, there has been a burgeoning interest in the role of moral distress and moral injury in health care. This column and the next will examine moral distress by clarifying the term, demonstrating how to apply the concept in consistent, practical, and meaningful ways, and describing how to support colleagues who have moral distress.

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.

More Than One ‘Right Thing to Do’

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.”

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. 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 aforementioned examples 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. There is no moral ambiguity there, just helplessness at the sometimes impossible situations.

Addressing moral distress means not just obtaining ethics consultations 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. For example, physicians might feel moral distress when constrained by their patient’s choices.

Examine Power Dynamics

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 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?

Course of Action

What can individual health care professionals do when feeling morally distressed? First, consider calling an ethics consultation. Second, anyone can

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. ■ 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 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.

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.

REFERENCES

1. Repenshek M. Moral distress: Inability to act or discomfort with moral subjectivity? Nurs Ethic s. 2009;16(6):734-742. doi:10.1177/0969733009342138

2. Brody H. The Healer’s Power. London: Yale University Press: 1992.