Medicine, Health Care and Philosophy

, Volume 21, Issue 4, pp 479–488 | Cite as

Rethinking moral distress: conceptual demands for a troubling phenomenon affecting health care professionals

  • Daniel W. TigardEmail author
Scientific Contribution


Recent medical and bioethics literature shows a growing concern for practitioners’ emotional experience and the ethical environment in the workplace. Moral distress, in particular, is often said to result from the difficult decisions made and the troubling situations regularly encountered in health care contexts. It has been identified as a leading cause of professional dissatisfaction and burnout, which, in turn, contribute to inadequate attention and increased pain for patients. Given the natural desire to avoid these negative effects, it seems to most authors that systematic efforts should be made to drastically reduce moral distress, if not altogether eliminate it from the lives of vulnerable practitioners. Such efforts, however, may be problematic, as moral distress is not adequately understood, nor is there agreement among the leading accounts regarding how to conceptualize the experience. With this article I make clear what a robust account of moral distress should be able to explain and how the most common notions in the existing literature leave significant explanatory gaps. I present several cases of interest and, with careful reflection upon their distinguishing features, I establish important desiderata for an explanatorily satisfying account. With these fundamental demands left unsatisfied by the leading accounts, we see the persisting need for a conception of moral distress that can capture and delimit the range of cases of interest.


Moral distress Nursing ethics Emotions Moral psychology 



For support during the research and writing of this paper, I thank the Murphy Institute’s Center for Ethics and Public Affairs at Tulane University. For helpful comments or conversations on issues addressed here, I greatly appreciate Nathan Biebel, Alison Denham, Georgina Morley, David Shoemaker, Chad Van Schoelandt, and two anonymous reviewers for this journal.


  1. Aiken, L., S. Clarke, D. Sloane, and J. Sochalski. 2001. Nurses’ reports on hospital care in five countries. Health Affairs 20 (3): 43–53.CrossRefGoogle Scholar
  2. Austin, W., M. Rankel, L. Kagan, V. Bergum, and G. Lemermeyer. 2005. To stay or to go, to speak or stay silent, to act or not to act: Moral distress as experienced by psychologists. Ethics & Behavior 15 (3): 197–212.CrossRefGoogle Scholar
  3. Austin, W., L. Kagan, M. Rankel, and V. Bergum. 2008. The balancing act: Psychiatrists’ experience of moral distress. Medicine, Health Care and Philosophy 11 (1): 89–97.CrossRefGoogle Scholar
  4. Baggs, J.G., M.H. Schmitt, and A.I. Mushlin, et al. 1999. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Critical Care Medicine 27 (9): 1991–1998.CrossRefGoogle Scholar
  5. Baur, V.E., A.A.M. Nistelrooij, and L. Vanlaere. 2017. The sensible health care professional: A care ethical perspective on the role of caregivers in emotionally turbulent practices. Medicine, Health Care and Philosophy 20 (4): 483–493.CrossRefGoogle Scholar
  6. Campbell, S.M., S.M. Ulrich, and C. Grady. 2016. A broader understanding of moral distress. The American Journal of Bioethics 16 (12): 2–9.CrossRefGoogle Scholar
  7. Corley, M. 2002. Nurse moral distress: A proposed theory and research agenda. Nursing Ethics 9 (6): 636–650.CrossRefGoogle Scholar
  8. Corley, M., and P. Selig. 1994. Prevalence of principled thinking by critical care nurses. Dimensions of Critical Care Nursing 13 (2): 96–103.CrossRefGoogle Scholar
  9. Corley, M., R.K. Elswick, M. Gorman, and T. Clor. 2001. Development and evaluation of a moral distress scale. Journal of Advanced Nursing 33 (2): 250–256.CrossRefGoogle Scholar
  10. Cribb, A. 2011. Integrity at work: Managing routine moral stress in professional roles. Nursing Philosophy 12 (2): 119–127.CrossRefGoogle Scholar
  11. De Raeve, L. 1998. Maintaining integrity through clinical supervision. Nursing Ethics 5 (6): 486–496.CrossRefGoogle Scholar
  12. Dudzinski, D.M. 2016. Navigating moral distress using the moral distress map. Journal of Medical Ethics 42: 321–324.CrossRefGoogle Scholar
  13. Elpern, E., B. Covert, and R. Kleinpell. 2005. Moral distress of staff nurses in a medical intensive care unit. American Journal of Critical Care 14 (6): 523–530.Google Scholar
  14. Epstein, E.G., and S. Delgado. 2010. Understanding and addressing moral distress. The Online Journal of Issues in Nursing 15(3):
  15. Fourie, C. 2015. Moral distress and moral conflict in clinical ethics. Bioethics 29 (2): 91–97.CrossRefGoogle Scholar
  16. Gowans, C. 1994. Innocence lost: An examination of inescapable wrongdoing. New York: Oxford University Press.Google Scholar
  17. Hamric, A. 2000. Moral distress in everyday ethics. Nursing Outlook 48: 199–201.CrossRefGoogle Scholar
  18. Hamric, A.B., and L.J. Blackhall. 2007. Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress and ethical climate. Critical Care Medicine 35 (2): 422–429.CrossRefGoogle Scholar
  19. Hume, D. 1739/40 (1978). A treatise of human nature. Eds. L.A. Selby-Bigge, and P.H. Nidditch, Oxford: Clarendon Press.Google Scholar
  20. Ives, J. 2014. A method of reflexive balancing in a pragmatic, interdisciplinary and reflexive bioethics. Bioethics 28 (6): 302–312.CrossRefGoogle Scholar
  21. Ives, J., and H. Draper. 2009. Appropriate methodologies for empirical bioethics: It’s all relative. Bioethics 23 (4): 249–258.CrossRefGoogle Scholar
  22. James, W. 1884. What is an emotion?. Mind 9: 188–205.CrossRefGoogle Scholar
  23. Jameton, A. 1984. Nursing practice: The ethical issues. Englewood Cliffs: Prentice-Hall.Google Scholar
  24. Jameton, A. 1993. Dilemmas of moral distress: Moral responsibility and nursing practice. AWHONN’s Clinical Issues in Perinatal and Women’s Health Nursing 4 (4): 542–551.Google Scholar
  25. Kalvemark, S., A. Hoglund, M. Hansson, P. Westerholm, and B. Arnetz. 2004. Living with conflicts: Ethical dilemmas and moral distress in the health care system. Social Science & Medicine 58 (6): 1075–1084.CrossRefGoogle Scholar
  26. Kelly, B. 1998. Preserving moral integrity: A follow-up study with new graduate nurses. Journal of Advanced Nursing 28 (5): 1134–1145.CrossRefGoogle Scholar
  27. Lange, C. 1885 (1912). The mechanism of the emotions. In The classical psychologists, ed. B. Rand, 672–684. Boston: Houghton Mifflin.Google Scholar
  28. Lutzen, K., A. Johansson, and G. Nordstrom. 2000. Moral sensitivity: Some differences between nurses and physicians. Nursing Ethics 7 (6): 520–530.CrossRefGoogle Scholar
  29. McCarthy, J., and R. Deady. 2008. Moral distress reconsidered. Nursing Ethics 15 (2): 254–262.CrossRefGoogle Scholar
  30. McCarthy, J., and C. Gastmans. 2015. Moral distress: A review of the argument-based nursing ethics literature. Nursing Ethics 22 (1): 131–152.CrossRefGoogle Scholar
  31. McConnell, T. 1996. Moral residue and dilemmas. In Moral dilemmas and moral theory, ed. H. E. Mason, 36–47. New York: Oxford University Press.Google Scholar
  32. Morley, G., J. Ives, C. Bradbury-Jones, and F. Irvine. 2017. What is ‘moral distress’? A narrative synthesis of the literature. Nursing Ethics. Scholar
  33. Musto, L., and P. Rodney. 2016. Moving from conceptual ambiguity to knowledgeable action: Using a critical realist approach to studying moral distress. Nursing Philosophy 17 (2): 75–87.CrossRefGoogle Scholar
  34. Nathaniel, A. 2006. Moral reckoning in nursing. Western Journal of Nursing Research 28 (4): 419–438.CrossRefGoogle Scholar
  35. Oakley, J. 1992. Morality and the emotions. London: Routledge.Google Scholar
  36. Prinz, J. 2004. Embodied emotions. In Thinking about feeling: Contemporary philosophers on emotions, ed. R. Solomon, 44–58. New York: Oxford University Press.Google Scholar
  37. Raines, M. 2000. Ethical decision making in nurses: Relationships among moral reasoning, coping style, and ethics stress. JONA’s Healthcare Law, Ethics & Regulation 2 (1): 29–41.CrossRefGoogle Scholar
  38. Redman, B., and M. Hill. 1997. Studies of ethical conflicts by nursing practice settings or roles. Western Journal of Nursing Research 19 (2): 243–250.CrossRefGoogle Scholar
  39. Rubin, J. 1996. Impediments to the development of clinical knowledge and ethical judgment in critical care nursing. In Expertise in nursing practice, eds. P. Benner, C. Tanner, and C. Chesla, 170–192. New York: Springer Publishing.Google Scholar
  40. Shavelson, L. 1998. A chosen death: The dying confront assisted suicide. Berkeley: University of California Press.Google Scholar
  41. Sinnott-Armstrong, W. 1988. Moral dilemmas. Oxford: Basil Blackwell.Google Scholar
  42. Stocker, M. 1990. Plural and conflicting values. New York: Oxford University Press.Google Scholar
  43. Tigard, D. 2016. Judicial discretion and the problem of dirty hands. Ethical Theory and Moral Practice 19 (1): 177–192.CrossRefGoogle Scholar
  44. Unruh, J. 2010. Moral distress: A living nightmare. Journal of Emergency Nursing 36 (3): 253–255.CrossRefGoogle Scholar
  45. Walzer, M. 1973. Political action: The problem of dirty hands. Philosophy and Public Affairs 2 (2): 160–180.Google Scholar
  46. Wilkinson, J.M. 1987/88. Moral distress in nursing practice: Experience and effect. Nursing Forum 23 (1): 16–29.CrossRefGoogle Scholar
  47. Williams, B. 1965. Ethical consistency. Proceedings of the Aristotelian Society 39 (Suppl 1): 103–124.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2017

Authors and Affiliations

  1. 1.Department of PhilosophyTulane UniversityNew OrleansUSA

Personalised recommendations