Moral Distress in Medical Education and Training
Moral distress is the experience of cognitive-emotional dissonance that arises when one feels compelled to act contrary to one’s moral requirements. Moral distress is common, but under-recognized in medical education and training, and this relative inattention may undermine educators’ efforts to promote empathy, ethical practice, and professionalism. Moral distress should be recognized as a feature of the clinical landscape, and addressed in conjunction with the related concerns of negative role modeling and the goals and efficacy of medical ethics curricula.
KeywordsEthic Education Moral Disengagement Graduate Medical Education House Staff Moral Distress
Conflict of Interest
The author declares no conflicts of interest.
- 1.Rushton C, Kaszniak AW, Halifax J. A framework for understanding moral distress among palliative care clinicians. Palliat Med. 2013 Sep;16(9):1074–1079. doi: 10.1089/jpm.2012.0490. Epub 2013 Jun 18.
- 2.DuBois JM, Burkemper J. Ethics education in U.S. medical schools: a study of syllabi. Acad Med. 2002;77(5):432–437.Google Scholar
- 3.Lehmann LS, et al. A survey of medical ethics education at U.S. and Canadian medical schools. Acad Med. 2004;79(7):682–689.Google Scholar
- 4.Frank JE. Conscientious refusal in family medicine residency training. Fam Med. 2011;43(5):330–333.Google Scholar
- 5.Knifed E, Goyal A, Bernstein M. Moral angst for surgical residents: a qualitative study. Am J Surg. 2010;199(4):571–576.Google Scholar
- 6.Rosenbaum JR, et al. Sources of ethical conflict in medical housestaff training: a qualitative study. Am J Med. 2004;116(6):402–407.Google Scholar
- 7.Wiggleton C, et al. Medical students’ experiences of moral distress: development of a web-based survey. Acad Med. 2010;85(1):111–117.Google Scholar
- 8.Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethic. 2009;20(4):330–342.Google Scholar
- 9.Mobley MJ, et al. The relationship between moral distress and perception of futile care in the critical care unit. Intensive Crit Care Nurs. 2007;23(5):256–263.Google Scholar
- 10.Leiter MP, Frank E, Matheson TJ. Demands, values, and burnout: relevance for physicians. Can Fam Physician. 2009;55(12):1224–1225.Google Scholar
- 11.Poole AD, Sanson-Fisher RW. Long-term effects of empathy training on the interview skills of medical students. Patient Couns Health Educ. 1980;2(3):125–127.Google Scholar
- 12.Winseman J, Malik A, Morison J, Balkoski V. Students’ views on factors affecting empathy in medical education. Acad Psychiatry. 2009;33(6):484–491.Google Scholar
- 13.Tavakol S, Dennick R, Tavakol M. Medical students’ understanding of empathy: a phenomenological study. Med Educ. 2012;46(3):306–316.Google Scholar
- 14.Cohen MJ, Kay A, Youakim JM, Balaicuis JM. Identity transformation in medical students. Am J Psychoanal. 2009;69(1):43–52.Google Scholar
- 15.Lomis KD, Carpenter RO, Miller BM. Moral distress in the third year of medical school; a descriptive review of student case reflections. Am J Surg. 2009;197:107–112.Google Scholar
- 16.Carrese JA, McDonald EL, Moon M, Taylor HA, Khaira K, Beach CM, Hughes MT. Everyday ethics in internal medicine resident clinic: an opportunity to teach. Med Educ. 2011;45(7):712–721.Google Scholar
- 17.Ousager J, Johannessen H. Humanities in undergraduate medical education: a literature review. Acad Med. 2010 Jun;85(6):988–998.Google Scholar
- 18.Cordingley L, Hyde C, Peters S, Vernon B, Bundy C. Undergraduate medical students’ exposure to clinical ethics: a challenge to the development of professional behaviours? Med Educ. 2007;41(12):1202–1209.Google Scholar
- 19.Hu YY, Fix ML, Hevelone ND, Lipsitz SR, Greenberg CC, Weissman JS, Shapiro J. Physicians’ needs in coping with emotional stressors: the case for peer support. Arch Surg. 2012 March;147(3):212–217.Google Scholar
- 20.Berger JT. Improving quality improvement for cardiopulmonary resuscitation. JAMA Intern Med. 2013. doi: 10.1001/jamainternmed.2013.10034.
- 21.Rogers DA, Boehler ML, Roberts NK, Johnson V. Using the hidden curriculum to teach professionalism during the surgery clerkship. J Surg Educ. 2012;69(3):423–427.Google Scholar
- 22.Ubel PA. The predictable irrationality of righteous minds, and the work of ethicists. Hastings Center Rep. 2013;43(3):18–22.Google Scholar
- 23.Stephens MB, Reamy BV, Anderson D, Olsen C, Hemmer PA, Durning SJ, Auster S. Writing, self-reflection, and medical school performance: the human context of health care. Mil Med. 2012;177(9 Suppl):26–30.Google Scholar
- 24.Self DJ, Baldwin JR, Wolinsky FD. Evaluation of teaching medical ethics by an assessment of moral reasoning. Med Educ. 1992;26(3):178–184.Google Scholar
- 25.Patenaude J, Niyonsenga T. Changes in students’ moral development during medical school: a cohort study. CMAJ. 2003;7:840–844.Google Scholar
- 26.Self DJ, Schrader DE, Baldwin JR, Wolinsky FD. The moral development of medical students: a pilot study of the possible influence of medical education. Med Educ. 1993;27(1):26–34.Google Scholar
- 27.Dubler NN, Liebman CB. Bioethics Mediation: A Guide to Shaping Shared Solutions. Vanderbilt University Press Nashville; 2011.Google Scholar
- 28.Back AL, Arnold RM, Baile WF, Fryer-Edwards KA, Alexander SC, Barley GE, Gooley TA, Tulsky JA. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007;167(5):453–460.Google Scholar
- 29.Hamric AB, Blackhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med. 2007;35(2):422–429.Google Scholar
- 30.Ganz FD, Raanan O, Khalaila R, Bennaroch K, Scherman S, Bruttin M, Sastiel Z, Fink NF, Benbenishty J. Moral distress and structural empowerment among a national sample of Israeli intensive care nurses. J Adv Nurs. 2013 Feb;69(2):415–424. doi: 10.1111/j.1365-2648.2012.06020.