The experience of ‘moral distress’ is an increasing focal point of contemporary medical and bioethics literature, yet it has received little attention in discussions intersecting with ethical theory. This is unfortunate, as it seems that the peculiar phenomenon may well help us to better understand a number of issues bearing both practical and theoretical significance. In this article, I provide a robust psychological profile of moral distress in order to shed a newfound light upon the longstanding problem of ‘dirty hands’. I argue that moral distress offers evidence of the existence of dirty hands situations. By examining moral distress and its relationship to cases of dirty hands, it appears that few of us are completely immune to susceptibility to these sorts of troubling experiences. With this concern in mind, I provide various recommendations to help alleviate our morally distressing personal and professional lives.
This is a preview of subscription content,to check access.
Access this article
Similar content being viewed by others
For examples of such utopianism, see Brandt (1972), Hare (1972), and Nielsen (2007). Additionally, Curzer (2002) offers what might be called a quasi-utopian outlook by arguing that conflicts between virtues do not undermine the consistency of morality. More recently, Tillyris (2017) provides a seemingly quasi-utopian account with his isolation of political integrity from moral conflict.
Here I say it is ‘normally’ quite troubling in recognition of the fact that being without moral distress may be just as troubling, if not more so. I will return to this point in discussing possible preventative measures, below.
See Jacobson (2013) for a persuasive account of the lorry driver’s irrational guilt or regret.
Here I have in mind the ‘rational sentimentalism’ advanced by D’Arms and Jacobson (2000b).
This inner conflict might be due to the recognition that nothing can be done to improve the negative situation. That is, given the action tendencies associated with each of these simpler states, the subject is at least inclined to improve the situation. However, as an instance of moral distress, one is frustrated, angered, or regretful while believing that the associated action tendency will not help. This appears to be consistent with our common use of ‘distress’ as describing overpowering adverse forces (we think of a sinking ship as being in distress). Here also we can effectively distinguish distress from stress, situations where one experiences a negative response—like frustration, anxiety, etc.—but can do something to improve the situation. So, where one is ‘under stress’ or ‘stressed out’ she simply has not yet fulfilled inclinations to improve things, to meet a deadline, and so on.
For encouraging me to make such distinctions explicit, I am extremely grateful to two anonymous reviewers.
See, of course, Williams (1981) for the notion of ‘agent-regret’. De Wijze (2005) provides a highly valuable alternative moral emotion, namely ‘tragic-remorse’ which, contra agent-regret, applies fittingly to deliberate wrongdoing. Still, as I claimed at the outset, my interest is less in the specific responses deemed appropriate and more in what the class of appropriate responses tells us about responsibility and the nature of our moral universe.
With this range of emotions, my account lends some support to those who characterize moral distress as an ‘umbrella’ concept (e.g. Hanna 2004; McCarthy and Deady 2008). Though, as I argued, the range of negative emotions alone is not enough to distinguish moral distress from its simpler, related states.
Shoemaker (2015, p. 86) aptly states that an agent would be ‘quite callous’ to perk up upon being counseled away from feelings like regret after ‘playing a key role in a tragic causal chain’.
Here I am indebted to an anonymous reviewer for helping to make this important connection to dirty hands.
We might think that the conflict here is simply an instance of ‘role strain’, namely where one’s personal and professional duties conflict. Notice, however, that the reluctant aid-in-dying physician personally maintains both conflicting values. Thus, while personal and professional duties certainly come apart (Cullity 2007), the subject is still understandably distressed when a value she maintains fails to be promoted.
As Chad Van Schoelandt has suggested to me, moral distress may be much like seeing an illusion. One is functioning properly where she is responding to the circumstances in ways that are somehow unfitting.
My analysis of understandable moral distress can be seen here as a generalized account of ‘tragic remorse’, given that both responses implicate some sense of wrongdoing without one’s wishing she had acted differently (de Wijze 2005, p. 466). Notice, however, that unlike some of the most prominent accounts of dirty hands, on my view, the subject need not be faced with the prospect of abetting in the evil projects of others.
In this way, the subject is alone in blaming herself, but appropriately so. I have discussed this phenomenon elsewhere (Tigard 2016).
While some theorists speak of victims having ‘standing to blame’, here we see a plausible notion of bystanders having (or not having) standing to comfort.
See Gowans (1994, pp. 226–228) for an insightful taxonomy of ‘tragic-making characteristics’—features of circumstances that display inescapable wrongdoing and, thereby, one’s morally spoiled condition.
Of course, I am not denying that dilemmas occur in healthcare. I am simply flagging that my interest is primarily in dirty handed practice, as it appears that practitioners, like effective political actors, should have some idea as to the best action to take, even in the most complex situations.
I gloss over this example only briefly, as I assume readers will be at least generally familiar with the widely discussed case and in recognition that the vast literature on torture cannot be adequately addressed here. I appreciate an anonymous reviewer’s remarks on this matter.
Here I have in mind Stocker’s (1976, p. 453) concern for harmony—namely, ‘between one’s motives and one’s reasons, values, justifications’—and the fact that modern ethical theories largely ignore this feature of moral life.
I thank an anonymous reviewer for raising this point. In fact, moral distress has been described as an ‘ethical canary’, warning us that something significant is amiss and demands our attention (Austin 2012).
For suggesting such obligations plausibly imposed upon institutions, I am grateful for the comments of an anonymous reviewer.
Gardner (2007) provides a persuasive account wherein both the principal actors as well as those who serve—perhaps unwillingly—as accomplices can be seen, to some extent, as sharing responsibility. For helping to make explicit the victimization of the morally distressed, I thank an anonymous reviewer.
This point might appear somewhat controversial, but it must be set aside for a future project (in preparation). Here, again, I am indebted to an anonymous reviewer’s helpful remarks.
Austin, Wendy. 2012. Moral Distress and the Contemporary Plight of Health Professionals. HEC Forum 24: 27–38.
Benner, Patricia. 1991. The Role of Experience, Narrative, and Community in Skilled Ethical Comportment. Advances in Nursing Science 14(2): 1–21.
Brandt, R.B. 1972. Utilitarianism and the Rules of War. Philosophy & Public Affairs 1(2): 145–165.
Campbell, Stephen M., Connie M. Ulrich, and Christine Grady. 2016. A Broader Understanding of Moral Distress. The American Journal of Bioethics 16(12): 2–9.
Corley, Mary C. 2002. Nurse Moral Distress: A Proposed Theory and Research Agenda. Nursing Ethics 9(6): 636–650.
Corley, Mary C., R.K. Elswick, Martha Gorman, and Theresa Clor. 2001. Development and Evaluation of a Moral Distress Scale. Journal of Advanced Nursing 33(2): 250–256.
Cullity, Garrett. 2007. The Moral, the Personal and the Political. In Politics and Morality, ed. Igor Primoratz, 54–75. London: Palgrave Macmillan.
Curzer, Howard J. 2002. Admirable Immorality, Dirty Hands, Care Ethics, Justice Ethics, and Child Sacrifice. Ratio 15(3): 227–244.
D’Arms, Justin, and Daniel Jacobson. 2000a. The Moralistic Fallacy: On the ‘Appropriateness’ of Emotions. Philosophy and Phenomenological Research 61(1): 65–90.
D’Arms, Justin, and Daniel Jacobson. 2000b. Sentiment and Value. Ethics 110(4): 722–748.
D’Arms, Justin, and Daniel Jacobson. 2006. Anthropocentric Constraints on Human Value. Edited by Russ Shafer-Landau. Oxford Studies in Metaethics 1: 99–126.
De Wijze, Stephen. 2005. Tragic-Remorse: The Anguish of Dirty Hands. Ethical Theory and Moral Practice 7(5): 453–471.
De Wijze, Stephen. 2007. Dirty Hands: Doing Wrong to do Right. In Politics and Morality, ed. Igor Primoratz, 3–19. London: Palgrave Macmillan.
De Wijze, Stephen. 2013. Punishing ‘Dirty Hands’: Three Justifications. Ethical Theory and Moral Practice 16(4): 879–897.
Dudzinski, Denise. 2016. Navigating Moral Distress Using the Moral Distress Map. Journal of Medical Ethics 42: 321–324.
Erlen, Judith A. 2001. Moral Distress: A Pervasive Problem. Orthopaedic Nursing 20(2): 76.
Fourie, Carina. 2015. Moral Distress and Moral Conflict in Clinical Ethics. Bioethics 29(2): 91–97.
Frijda, Nico H. 1986. The Emotions. Cambridge: Cambridge University Press.
Frijda, Nico H. 1988. The Laws of Emotion. American Psychologist 43(5): 349–358.
Gardner, John. 2007. Complicity and Causality. In Offences and Defences: Selected Essays in the Philosophy of Criminal Law, ed. J. Gardner, 57–76. New York: Oxford University Press.
Gowans, Christopher. 1994. Innocence Lost: An Examination of Inescapable Moral Wrongdoing. New York: Oxford University Press.
Hamric, Ann B., and Leslie 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.
Hanna, Debra. 2004. Moral Distress: The State of the Science. Research and Theory for Nursing Practice 18(1): 73–93.
Hare, R.M. 1972. Rules of War and Moral Reasoning. Philosophy & Public Affairs 1(2): 166–181.
Hollis, Martin. 1982. Dirty Hands. British Journal of Political Science 12(4): 385–398.
Jacobson, Daniel. 2013. Regret, Agency, and Error. In Oxford Studies in Agency and Responsibility, vol. 1, ed. David Shoemaker. New York: Oxford University Press.
Jameton, Andrew. 1984. Nursing Practice: The Ethical Issues. New Jersey: Prentice-Hall.
Jameton, Andrew. 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.
Kälvemark, Sofia, Anna Hoglund, Mats Hansson, Peter Westerholm, and Bengt Arnetz. 2004. Living With Conflicts—Ethical Dilemmas and Moral Distress in the Health Care System. Social Science and Medicine 58(6): 1075–1084.
McCarthy, Joan, and Rick Deady. 2008. Moral Distress Reconsidered. Nursing Ethics 15(2): 254–262.
Nagel, Thomas. 1972. War and Massacre. Philosophy & Public Affairs 1(2): 123–144.
Nagel, Thomas. 1979. Moral Luck. In Mortal Questions, ed. T. Nagel, 24–38. New York: Cambridge University Press.
Nielsen, Kai. 2007. There Is No Dilemma of Dirty Hands. In Politics and Morality, ed. Igor Primoratz, 20–37. London: Palgrave Macmillan.
Oakley, Justin. 1992. Morality and the Emotions. London: Routledge.
Roberts, Robert C. 2003. Emotions: An Essay in Aid of Moral Psychology. Cambridge: Cambridge University Press.
Rushton, C.H. 1992. Care-Giver Suffering in Critical Care Nursing. Heart & Lung: The Journal of Critical Care 21(3): 303–306.
Shoemaker, David. 2015. Responsibility from the Margins. New York: Oxford University Press.
Sinnott-Armstrong, Walter. 1988. Moral Dilemmas. Oxford: Basil Blackwell.
Stocker, Michael. 1976. The Schizophrenia of Modern Ethical Theories. The Journal of Philosophy 73(14): 453–466.
Stocker, Michael. 1990. Plural and Conflicting Values. New York: Clarendon Press; Oxford University Press.
Strawson, P.F. 1962. Freedom and Resentment. Proceedings of the British Academy 48: 1–25.
Szigeti, András. 2015. Sentimentalism and Moral Dilemmas. Dialectica 69(1): 1–22.
Tigard, Daniel. 2016. Judicial discretion and the problem of dirty hands. Ethical Theory and Moral Practice 19(1): 177–192.
Tigard, Daniel. 2017. Rethinking moral distress: Conceptual demands for a troubling phenomenon affecting health care professionals. Medicine, Health Care and Philosophy. https://doi.org/10.1007/s11019-017-9819-5.
Tillyris, Demetris. 2017. Political Integrity and Dirty Hands: Compromise and the Ambiguities of Betrayal. Res Publica 23: 475–494.
Unruh, Julie A. 2010. Moral Distress: A Living Nightmare. Journal of Emergency Nursing 36(3): 253–255.
Wallace, R. Jay. 1994. Responsibility and the Moral Sentiments. Cambridge, MA: Harvard University Press.
Walzer, Michael. 1973. Political Action: The Problem of Dirty Hands. Philosophy & Public Affairs 2(2): 160–180.
Walzer, Michael. 1977. Just and Unjust Wars: A Moral Argument with Historical Illustrations. New York: Basic Books.
Watson, Gary. 2004. Agency and Answerability. Oxford: Clarendon Press.
Wilkinson, Judith M. 1987. Moral Distress in Nursing Practice: Experience and Effect. Nursing Forum 23(1): 16–29.
Williams, Bernard. 1973. Ethical Consistency. In Problems of the Self, ed. B. Williams. Cambridge: Cambridge University Press.
Williams, Bernard. 1981. Moral Luck. Cambridge: Cambridge University Press.
Williams, Bernard. 1994. Shame and Necessity. Berkeley, CA: University of California Press.
The debts of gratitude I acquired during my work on this essay begin with my friend and colleague, Nathan Biebel, whose enthusiasm for discussing these issues was ceaseless. For support during the initial writing, a debt of gratitude is owed to the Murphy Institute’s Center for Ethics and Public Affairs at Tulane University. For providing valuable comments on earlier pieces of this work, I am extremely grateful to Alison Denham, Katharina Hammler, Thomas Mulligan, David Shoemaker, Chad Van Schoelandt, and two anonymous reviewers at Res Publica. Finally, I want to thank the participants in my 2017 seminar, Responsibility and Moral Conflicts, at the Sherwin B. Nuland Summer Institute in Bioethics at Yale University.