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

Abstract

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.

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Notes

  1. 1.

    This case is a dramatization of real-life events conveyed to me in conversation at a recent bioethics conference. Names have been changed.

  2. 2.

    Elsewhere, I have argued that moral agents with professional duties—particularly political actors and medical professionals—should often experience guilt and related emotional responses when their official decisions set back others' interests or even their own. See Tigard (2016).

  3. 3.

    Here I am indebted to an anonymous reviewer for encouraging me to make this important distinction between guilt (and regret, etc.) and moral distress.

  4. 4.

    The following scenario is an adaptation of a case presented by Jameton (1984, p. 6).

  5. 5.

    Indeed, if this alone describes moral distress, the concept is questionable at best. For helping to raise such skepticism concerning Jameton’s (1984) view, I thank an anonymous reviewer.

  6. 6.

    This case is a hypothetical situation of a fellow practitioner seeking aid-in-dying consultation from Shavelson (1998).

  7. 7.

    This phenomenon has been discussed at length, for example, by Williams (1965), Walzer (1973), Stocker (1990), Gowans (1994), and McConnell (1996).

  8. 8.

    For supplying the apt description “moral confusion” I am grateful for an anonymous reviewer’s reflection upon this case.

  9. 9.

    Fourie (2015, p. 93) aptly applies this line of criticism to Jameton (1984, 1993). See, also, Musto and Rodney (2016, pp. 80–81) for an articulation of the fallacy in “conflating the measures of moral distress with what moral distress actually is.”

  10. 10.

    This difficulty points to some limitations in the aims and conclusion advanced by Morley et al. (2017).

  11. 11.

    Here I am loosely describing what is often referred to as an affective theory of emotions, in both its purely psychic and its bodily versions. Historical accounts of this view are found in Hume (1739/40), James (1884), and Lange (1885). For a more recent, albeit qualified defense of the James–Lange theory, see Prinz (2004).

  12. 12.

    See the recent work of Baur et al. (2017) for an account of emotional decision-making in health care practice.

  13. 13.

    For related variations and a proposed taxonomy of moral distress, see Campbell et al. (2016).

  14. 14.

    Jameton later makes clear that he is interested primarily—if not entirely—in the causes of distress, rather than the nature of the condition itself: “Nurses feel guilt and real moral distress when they perform procedures that they feel are morally wrong and can find no way to avoid. Incompetent practice and ‘medically justified’ pain…are common causes of nurses’ distress” (1984, p. 283, italics added).

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Acknowledgements

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.

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Correspondence to Daniel W. Tigard.

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Tigard, D.W. Rethinking moral distress: conceptual demands for a troubling phenomenon affecting health care professionals. Med Health Care and Philos 21, 479–488 (2018). https://doi.org/10.1007/s11019-017-9819-5

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Keywords

  • Moral distress
  • Nursing ethics
  • Emotions
  • Moral psychology