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Moral Distress: Ethics in Black and White
Chaplains who work in ICUs and in end of life care may be familiar with the distinction between ethical dilemmas and moral distress. An ethical dilemma arises where various options must be considered with reference to competing, yet legitimate, moral claims. Moral distress is triggered when someone believes that he or she is being prevented from doing the right thing, or is being forced to do the wrong thing. Ethical dilemmas take place in the grey area; moral distress occurs when things appear to be black and white.
Most studies of moral distress have involved nurses, in whom moral distress may be triggered when they are directed to carry out orders – such as aggressive treatment near the end of life – with which they do agree, and which they feel powerless to challenge. A recent study, by Ann Hamric, a nurse-researcher at the University of Virginia, collected perspectives from physicians and nurses working in the same ICUs, in an effort to understand how moral distress might be experienced by physicians, and how the values and responsibilities of different professions might account for different perspectives on similar situations. Here were some of her findings:
Nurses are “more continuously confronted by the patient’s suffering.” Physicians shoulder the “burden of responsibility” for signing orders. Both of these
responsibilities can be distressing.
Nurses tended to be “more pessimistic” than physicians about the prognosis of individual patients; thus, aggressive treatment triggered moral distress. However, because some of these patients recovered, the nurses’ pessimism was not always a reliable guide to ethical action.
Physicians’ daily schedules usually allowed them “a break from the stress of the ICU,” while nurses were tied to the unit. This may help explain why physicians tend to perceive morally distressing events as happening less frequently, and why nurses tend to perceive them as happening more frequently.
Physicians tended to believe that they “collaborate” with nurses; however, nurses did not tend to characterize their relationships with physicians as collaborative.
Hamric notes that ethics guidelines often advocate “collaboration” without describing the ingredients of successful collaboration. Because of the power imbalance between physicians and nurses, successful collaboration depends on structured activities: a practice of team meetings; a requirement that family meetings include nurses; the routine involvement of palliative care teams, which tend to include nurses, in the ICU.
These findings and conclusions may be of great interest to chaplains, for at least three reasons. Chaplains tend to be aware of what’s going on with nurses. Chaplains may, like nurses, feel distressed when they are involved in situations they believe they cannot change, and believe to be morally wrong. And chaplains may, like nurses, feel shut out of “collaboration” on the units in which they work.
I’m not aware of any studies of moral distress among chaplains, and so I’d like to hear your thoughts on this issue. In what clinical situations have you experienced moral distress? What actions, whether on your part or another’s part, alleviated your moral distress? What, in your experience, are the ingredients of successful collaboration on the clinical care team when this team involves the chaplain?
For further reading:
Ann B. Hamric and Leslie J. Blackhall," Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate," Critical Care Medicine 35, no. 2 (2007): 422-29.
Nancy Berlinger is Deputy Director and Research Associate at The Hastings Center. Her research interests focus on clinical ethics and include end of life care; ethics in health care chaplaincy; conscientious objection and moral distress in health care; and patient safety and the resolution of medical harm. Her broader interests include bioethics issues in cancer care, narrative ethics, and medical humanities.
As Deputy Director, she manages the Center’s organizational capacity-building initiative, Bioethics and the Public Interest, which has received major support from the Ford Foundation.
Berlinger is the author of After Harm: Medical Error and the Ethics of Forgiveness
(Johns Hopkins, 2005), which will be released in paperback in fall 2007. She serves on the ethics research group of the Joint Commission, the ethics faculty of the American Society of Healthcare Risk Managers (ASHRM), the bioethics committees at Montefiore Medical Center, Bronx, New York and at Richmond of New York, and the editorial board of Medical Ethics Advisor
. She is a frequent presenter at grand rounds and other ethics education programs for health care professionals. She volunteers on the Chaplaincy Service at Memorial Sloan-Kettering Cancer Center in New York City.
She is a graduate of Smith College and holds the Ph.D. in English Literature from the University of Glasgow and the M.Div. in Christian Ethics from Union Theological Seminary.
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