Journal of Medicine and Philosophy, 40: 102–120, 2015 doi:10.1093/jmp/jhu048 Advance Access publication December 10, 2014

A Philosophical Taxonomy of Ethically Significant Moral Distress

LAURENCE B. McCULLOUGH* Baylor College of Medicine, Houston, Texas, USA *Address correspondence to: Laurence B. McCullough, PhD, Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, MS 240, Houston, TX 77030, USA. E-mail: [email protected]

Moral distress is one of the core topics of clinical ethics. Although there is a large and growing empirical literature on the psychological aspects of moral distress, scholars, and empirical investigators of moral distress have recently called for greater conceptual clarity. To meet this recognized need, we provide a philosophical taxonomy of the categories of what we call ethically significant moral distress: the judgment that one is not able, to differing degrees, to act on one’s moral knowledge about what one ought to do. We begin by unpacking the philosophical components of Andrew Jameton’s original formulation from his landmark 1984 work and identify two key respects in which that formulation remains unclear: the origins of moral knowledge and impediments to acting on that moral knowledge. We then selectively review subsequent literature that shows that there is more than one concept of moral distress and that explores the origin of the values implicated in moral distress and impediments to acting on those values. This review sets the stage for identifying the elements of a philosophical taxonomy of ethically significant moral distress. The taxonomy uses these elements to create six categories of ethically significant moral distress: challenges to, threats to, and violations of professional integrity; and challenges to, threats to, and violations of individual integrity. We close with suggestions about how the proposed philosophical taxonomy of ethically significant moral distress sheds light on the concepts of moral residue and crescendo effect of moral distress and how the proposed taxonomy might usefully guide prevention of and future © The Author 2014. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: [email protected]

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TESSY A. THOMAS Baylor College of Medicine & Texas Children’s Hospital, Houston, Texas, USA



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qualitative and quantitative empirical research on ethically significant moral distress. Keywords: ethically significant moral distress, individual integrity, moral distress, philosophical taxonomy, professional integrity I. Introduction Downloaded from http://jmp.oxfordjournals.org/ at University of Massachusetts Medical School on March 17, 2015

In 1984 Andrew Jameton introduced into the clinical ethics literature the concept of “moral distress” to characterize circumstances in which “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (Jameton, 1984, 6). Jameton called attention to the psychological dimensions of the concept, when he explained that “moral distress” names the “painful feelings and/or psychological disequilibrium that occurs when nurses are conscious of the morally appropriate action a situation requires but cannot carry out that action because of institutionalized obstacles” (Jameton, 1984, 382). Jameton’s seminal work launched three decades of qualitative and quantitative empirical studies of moral distress. Much of this research at first investigated the psychological dimensions of moral distress among nurses, especially critical care nurses. This initial focus soon expanded, with moral distress now considered to be a critical problem that confronts multiple healthcare professionals beyond the original target population of critical care nurses, including physicians, respiratory therapists, noncritical care nurses, and social workers, as well as the health system at large (Sporrong et al., 2005; Schwenzer & Wang, 2006; Hamric & Blackhall, 2007; McClendon & Buckner, 2007; Austin et al., 2008; Forde & Aasland, 2008; Lee & Dupree, 2008; Chen, 2009; Lomis, Carpenter, & Miller, 2009). Recent literature demonstrates that moral distress has become an international concern and has implications for satisfaction, recruitment, and retention of healthcare professionals as well as for the delivery of safe and competent quality patient care (Pauly, Varcoe, & Storch, 2012). Furthermore, increased effort has been devoted to understanding and addressing moral distress because the residue (long-term) and crescendo (reinforcing) effects of moral distress threaten to undermine professional integrity (Epstein & Hamric, 2009) and moral integrity (Hamric, 2012). Jameton’s formulation has remained the touchstone for this large and growing body of empirical qualitative and quantitative research. It is therefore significant that a series of articles in HEC Forum from a 2010 symposium on moral distress concluded that the development of a conceptual model for moral distress is now urgently needed to bolster further research on the subject: “research on moral distress has been plagued by a lack of conceptual and theoretical clarity that, in turn, has hampered action on moral distress in education, policy, and practice” (Pauly, Varcoe, & Storch, 2012, 2). Unfortunately, none of the papers from this symposium provided the

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needed conceptual model. In introducing a series of papers in Bioethical Inquiry in 2013, Peter remarked on the “variability of definitions” of moral distress in the literature. In the absence of a clear philosophical concept of moral distress, scholars and investigators of the subject are at ongoing risk of confusion (Peter, 2013) about what should count as moral distress. None of the papers that followed provided the needed conceptual clarity. Chronic conceptual confusion should be regarded as a shortcoming in the literature on any subject. The purpose of this article is to address and resolve this chronic conceptual confusion, by providing a philosophical taxonomy1 of the categories of what we call “ethically significant moral distress.” Jameton’s original formulation implicitly included an ethically significant phenomenon: the judgment that one is not able, to different degrees, to act on one’s moral knowledge about what one ought to do in specific clinical circumstances because of impediments. These impediments are understood to be external to the individual, for example, organizational policies and practices, as well as the behavior of clinicians toward other clinicians. While this judgment surely has important psychological sequelae, ranging from anxiety through depression to burnout, the judgment itself originates in an ethical concern: not being able, to differing degrees, to act on one’s knowledge about what one ought to do. We call this judgment, the ethical origin of the psychological manifestations of moral distress, “ethically significant moral distress.” On Jameton’s 1984 formulation it appears that there is a single concept of ethically significant moral distress. We show that, on closer examination, this appearance gives way to a more complex philosophical picture: there are varieties of ethically significant moral distress. There is therefore the need for a philosophical taxonomy that displays the conceptually distinct categories of ethically significant moral distress. In such a taxonomy “ethically significant moral distress” names six such categories: challenges to, threats to, and violations of professional integrity; and challenges to, threats to, and violations of individual integrity. We begin by unpacking the philosophical components of Jameton’s original formulation (1984) and identify two key respects in which that formulation remains unclear: the origins of moral knowledge and impediments to acting on that moral knowledge. We then selectively review efforts in the subsequent literature that show that there is more than one concept of moral distress, explore the origin of the values implicated in moral distress, and explore the impediments to acting on those values. This review sets the stage for identifying the elements of the proposed philosophical taxonomy. We then present the taxonomy of ethically significant moral distress that identifies individually necessary and jointly sufficient conditions for each of the six varieties of ethically significant moral distress. We close with suggestions about how the proposed philosophical taxonomy of ethically



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significant moral distress sheds additional light on the concepts of moral residue and the crescendo effect in moral distress and how the taxonomy might usefully guide prevention of and future qualitative and quantitative empirical research on ethically significant moral distress. II.  UNPACKING THE PHILOSOPHICAL COMPONENTS OF JAMETON’S ORIGINAL FORMULATION OF THE CONCEPT OF MORAL DISTRESS

III.  THREE KEY CONTRIBUTIONS OF THE RECENT LITERATURE TO THE ELEMENTS OF THE PROPOSED TAXONOMY In this section of the article, we undertake a philosophical investigation of recent literature on the concept of moral distress that makes three key contributions to the proposed philosophical taxonomy of ethically significant moral distress: the suggestion that there are multiple concepts; the origin of values implicated in ethically significant moral distress in integrity; and the impediments to acting on those values. The literature on moral distress is very large, making a systematic review of it a separate undertaking beyond the scope of this article. We therefore examined the recent literature for attempts to articulate the concept of moral distress and selected those that appeared to represent an extension of Jameton’s formulation and that also point toward a philosophical taxonomy of ethically significant moral distress. The resulting review is therefore selective rather than systematic, an approach that has support in the methodologic literature of normative medical ethics (DeGrazia & Beauchamp, 2010).

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Jameton’s original formulation of the concept of moral distress identified two components: (a) moral knowledge about what one ought to do in specific circumstances, and (b) organizational constraints on implementing that knowledge. In 1993 Jameton further characterized moral distress as initial and reactive. Initial moral distress “occurs when the person feels frustration, anger, and anxiety when faced with institutional obstacles and interpersonal conflict about values” (Jameton, 1993, 544). Reactive moral distress is the “guilt, frustration, and anger that occurs when people do not act upon their initial distress” (Jameton, 1993, 544). Jameton’s account of moral distress suggests that the origin of the moral knowledge of what one ought to do is in an individual’s values. The sources of an individual’s values are not identified. His account also suggests that moral distress is triggered when an individual encounters external impediments that limit, as constraints or obstacles, one’s ability to act on one’s moral knowledge. The nature of these external factors or forces is not explained. As a consequence, their impact on one’s values remains unclear.

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More Than One Concept of Ethically Significant Moral Distress In a widely cited article, McCarthy and Deady elaborate on Jameton’s conception:

They go on to characterize moral distress as a cluster concept (McCarthy & Deady, 2008). An umbrella or cluster concept has a number of components, not all of which have to apply in every situation in order for the concept to apply. To prevent confusion when deploying a cluster concept, its user must always specify which components are being invoked. McCarthy and Deady’s account is useful because it suggests that there is not a single concept of moral distress. Identifying the varieties of ethically significant moral distress therefore becomes one of the tasks of the philosophical taxonomist. Origin of Values Implicated in Moral Distress in Professional and Individual Integrity Lunardi’s brief exposition makes an important contribution. She suggests that moral distress constrains what she calls “sustainable attitudes” of healthcare professionals (Lunardi, 2013, 311). In our view, the values implicated in “sustainable attitudes” are durable values, not temporary or transient. Peter makes an important addition when she notes that moral distress involves “a challenge that arises when one has an ethical or moral judgment about care that differs from that of others in charge” (Peter, 2013, 298). In our view, the use of “others” suggests that the durable values implicated in moral distress originate in one’s professional role. Lützén and Ewalds-Kvist’s account sheds some light on what those values might be when they write: “When events and demands threaten a person’s most important values and fundamental assumptions about the world, this threat is accompanied by a feeling of not being in control” (Lützén & Ewalds-Kvist, 2013, 318). In our view, durable values become worth sustaining precisely because they are important and fundamental in one’s life. Peter and Liaschenko appeal to the work of Kelly (1998) to make a connection between moral distress and integrity: A well-known study by Kelly (1998) explored how new graduates of nursing adapt to hospital nursing and what they perceive to be key influences in their values and roles. These neophyte nurses experience moral distress as they struggle to preserve their moral integrity. Moral distress is felt most intensely when they realize that they

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As it is currently understood, we think that it is best viewed as an umbrella concept that captures the range of experiences of individuals who are morally constrained. Generally speaking, when individuals make moral judgements about the right course of action to take in a situation, and they are unable to carry it out, they may experience moral distress. In short, they know what is the right thing to do, but they are unable to do it; or they do what they believe is the wrong thing. (McCarthy & Deady, 2008, 254)



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can never reach their ideals of patient care that are central to their moral identities as nurses. (Peter & Liaschenko, 2013, 340)

The struggle to preserve moral integrity resulted in moral distress. Moral distress manifests itself as the principal component of psychological responses to social forces. When it is experienced that one’s behavior is inconsistent with strongly held moral beliefs, moral distress occurs. (Kelly, 1998, 1141)

Unlike Peter and Liaschenko, Kelly provides an account of integrity. For Kelly, moral integrity relates to “preserving self and identity” (Kelly, 1998, 1137): “Preserving moral integrity is an attempt to maintain a valued professional identity” (Kelly, 1998, 1141). Epstein and Hamric understand moral distress to involve “erosion of moral integrity” (Epstein & Hamric, 2009). Their account and Kelly’s treat integrity broadly, suggesting that it includes both professional integrity and individual integrity. Identifying the varieties of ethically significant moral distress related to professional and individual integrity therefore becomes one of the tasks of the philosophical taxonomist. Impediments to Acting on Professional and Individual Integrity Laabs notes that moral distress occurs when “moral integrity is in jeopardy, compromised, or betrayed” (Laabs, 2011, 432). Laabs’ account of integrity is the following: “Moral integrity has been described as living up to one’s personal moral code, so that one can sleep at night, or live with oneself, having demonstrated courage, patience, and perseverance in the face of conflict” (Laabs, 2011, 431). In our view, this suggests that there is a variety of impediments, of differing ethical significance, to the ability to act on one’s professional and individual integrity. Hamric understands moral distress to involve “threats to integrity” (Hamric, 2012, 39). It follows that: Moral distress differs from other forms of emotional distress. It is important precisely because it is so powerful and so destructive to the moral agency and integrity of healthcare providers. Experiences of moral distress compromise providers’ core values or duties, which are the fundamental ingredients of their moral integrity. (Hamric, 2012, 47)

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In our view, this suggests that the durable values implicated in moral distress originate in nurses’—or other healthcare professionals’—professional identity and ability to uphold professional standards that express professional integrity, which is the ground of professional identity. Stated more precisely, durable values originate in the virtue of professional integrity, which Beauchamp and Childress (2013, 40–42) characterize as one of five “focal virtues.” Kelly makes an explicit connection between the virtue of integrity and moral distress:

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IV.  ELEMENTS OF A PHILOSOPHICAL TAXONOMY OF ETHICALLY SIGNIFICANT MORAL DISTRESS We summarize our work so far. Jameton introduced the concept of “moral distress,” to characterize circumstances in which “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (Jameton, 1984, 6). We introduced the concept of ethically significant moral distress: the intellectual, not psychological, experience of making a judgment that one is not able, to differing degrees, to act on one’s moral knowledge. Our philosophical investigation of selected literature has the following result: there are varieties of ethically significant moral distress, because the durable values implicated in ethically significant moral distress originate in both professional and individual integrity, and because there is a variety of impediments that trigger ethically significant moral distress. We turn now to the articulation of the elements of a philosophical taxonomy that classifies, by distinguishing among, the varieties of ethically significant moral distress. We first distinguish professional from individual integrity. We then distinguish among challenges to, threats to, and violations of professional and individual integrity. The proposed taxonomy maps professional and individual integrity onto challenges, threats, and violations to create six categories of ethically significant moral distress. Professional and Individual Integrity As noted above, Beauchamp and Childress identify integrity as one of five “focal virtues:” “In its most general sense, ‘moral integrity’ means soundness, reliability, wholeness, and integration of moral character. In a more restricting sense, the term refers to objectivity, impartiality, and fidelity in adherence to moral norms” (Beauchamp & Childress, 2013, 40). In our view, sustained commitments to intellectual and moral excellence define this “adherence to

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Lützén and Ewalds-Kvist (2013) elaborate on impediments to acting on judgments based on fundamental values and beliefs. Impediments that threaten such values and beliefs constitute a component of the concept of moral distress. Lützén and Ewalds-Kvist make a crucial contribution when they point out: “In morally conflicting situations, the commitment to professional values and experiencing meaning in all patient care is threatened” (Lützén & Ewalds-Kvist, 2013, 319). In our view, threats and challenges to one’s commitment to professional values, that is, to professional integrity, are among the impediments to acting on one’s professional and individual integrity. Identifying the varieties of impediments to acting on one’s professional and individual integrity therefore becomes one of the tasks of the philosophical taxonomist.



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moral norms” and create the “soundness, reliability, wholeness, and integration or moral character.” As such, integrity is a bedrock virtue, a sine qua non for the moral life of moral agents. Moral agency based on the virtue of integrity becomes a way of life worth living. Integrity thus becomes essential to medicine as “moral enterprise” (Pellegrino, 1987, 8). Commitments to excellence in patient care define this moral endeavor, because such a commitment provides the “soundness, reliability, wholeness, and integration” of professional character. In our view, in the health care professions, the virtue of professional integrity requires two commitments. These were first elaborated in the history of medical ethics by the Scottish physician-ethicist John Gregory (1724– 1773), and the English physician-ethicist Thomas Percival (1740–1804). They invented the ethical concept of medicine as a profession, to which professional integrity is foundational (McCullough, 2006). First, professional integrity requires the sustained commitment to intellectual excellence. For Gregory and Percival this meant conforming clinical judgment, decision making, and practice to the discipline of Baconian, “experience”-based reasoning. Francis Bacon (1561–1626) did not use “experience” as we do, to name idiosyncratic, potentially biased personal experiences. For Bacon and his followers in 18th-century British medicine, “experience” named something very different: the carefully observed and analyzed results of natural experiments (such as observing the course of conditions, diseases, disabilities, and injuries and their responses to clinical management) and controlled experiments (such as breaking down a compound medication into its components and testing each separately to identify their clinical effects on the course of conditions, diseases, disabilities, or injuries). In 21st century medicine, experience-based medicine has become the deliberative practice of medicine: clinical judgment, decision-making, and clinical management that are evidence-based, rigorous, transparent, and accountable (McCullough, 2006). Second, professional integrity requires the sustained commitment to moral excellence. For Gregory and Percival this meant that the physician achieves moral excellence by making the patient’s health-related interests the professional’s primary concern and motivation, while keeping self-interest systematically secondary. This commitment to moral excellence should guide physicians and other healthcare professionals in the responsible management of conflicts of interest (conflicts between professional responsibility in patient care, research, and education, on the one hand, with self-interest, on the other hand). This commitment to moral excellence should also guide physicians and other healthcare professionals in the responsible management of conflicts of commitment (conflicts between professional responsibility in patient care, research, and education, on the one hand, and obligations to others than patients in the healthcare professional’s life; McCullough, 2006). The commitment to moral excellence creates a social institute and practice

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whose “members are bound to each other by a set of commonly held ethical commitments whose purpose is something other than mere self-interest” (Pellegrino, 1990, 225). Healthcare professionals are morally formed not just by the requirements of professional integrity. Healthcare professionals, like all human beings, are also morally formed by the requirements of individual integrity: sustained commitments to intellectual and moral excellence that originate in ways of life other than the healthcare professions. Individual integrity requires the sustained commitment to intellectual excellence: conforming one’s judgment, decision making, and behavior to standards of intellectual excellence, which may originate in such sources as one’s religious faith, philosophical reflection, powerful role models in one’s life, and upbringing in one’s family and family history. Individual integrity also requires the sustained commitment to moral excellence: putting the interests of others in one’s life outside the clinical setting ahead of one’s own. Obviously, the interests of family members—spouse, children, and frail elderly parents—loom large in the moral lives of healthcare professionals in their lay lives. The sustained commitment to the protection and promotion of the interests of others produces the durable values that constitute individual integrity. Professional and individual integrity become the sources of durable values and judgments based on such values that constitute the moral knowledge at the center of Jameton’s (1984) original formulation of the concept of moral distress. As a consequence, one of the most important moral products of professional integrity is the sense of self-worth that results from making sustained commitments to intellectual and moral excellence in patient care, research, and education. Similarly, individual integrity generates one’s sense of self-worth as a human being: mattering in the lives of others and therefore justifiably mattering to others. Professional and individual integrity thus play major, and often insufficiently appreciated, roles in generating the obligation to respect healthcare professionals as professionals and as persons. In the HEC Forum issue referenced above, it was proposed that moral distress should be understood as “the experience of being seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards. It is a relational experience shaped by multiple contexts, including the socio-political and cultural context of the workplace environment” (Varcoe et al., 2012, 59). On the basis of the account we have provided of professional and individual integrity, we can elaborate on this proposal. Professional integrity is indeed relational, in that it is sustained only by healthcare professionals working together to sustain their professional integrity. In this respect, organizational culture (the policies and practices of an organization, what its leadership encourages and discourages, and what its leadership tolerates, including, especially, leaders tolerating what they should not tolerate) becomes crucial. In the absence of an organizational



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culture committed to professionalism in patient care, research, and education, it becomes impossible to sustain one’s professional integrity (Chervenak & McCullough, 2005). This is also true of individual integrity. In the absence of a supportive organizational culture, respect for individuals as persons becomes impossible to sustain. This reflects the social aspect of the intrapersonal component of individual integrity and the coherence that it creates in one’s intellectual and moral life.

Impediments to acting on professional and individual integrity define the “institutional constraints” in Jameton’s original formulation of the concept of moral distress. We propose that impediments to acting on integrity-based moral judgments about what one ought to do take the form of challenges to, threats to, and violations of professional and individual integrity. Challenges to professional and individual integrity Professional and individual integrity become challenged when the circumstances in which one finds oneself create incentives that, if acted on, weaken the self-discipline and commitment to the care of others required by professional and individual integrity. It becomes hard to do the right thing, inasmuch as such incentives distract one’s attention and activate self-interest. Professional and moral integrity can come under challenge when circumstances in which one finds oneself do not support integrity. The impediments to doing the right thing become more formidable, and doing the right thing starts to require levels of self-sacrifice that are very demanding; one struggles to maintain one’s identity that originates in professional or individual commitments to intellectual and moral excellence. In such circumstances, one becomes morally frayed; the coherence in the moral life that integrity creates is called into question. Impediments that create challenges to professional and individual are distinctive in that they are not permanent and therefore often give way when opposed. Challenges to professional and individual integrity are removable by asserting professional or individual integrity, depending on whether professional or individual commitments to intellectual and moral excellence are at stake. In our view, the concept of challenges to professional and individual integrity captures the meaning of Laab’s concept of moral integrity being in “jeopardy” (Laabs, 2011, 432). Threats to professional and individual integrity Challenges to integrity grow in intensity as the hostility of one’s circumstances to sustaining one’s integrity increases, marking the transition from situations in which professional or individual integrity is challenged to situations in

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Impediments to Acting on Professional and Individual Integrity: Challenges, Threats, and Violations

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Violations of professional and moral integrity Professional and individual integrity become violated when the impediments that one confronts are not removable and so powerful that one finds oneself completely unable to do the right thing, professionally or individually, and thus even hope to conform to the commitments required by professional or individual integrity. In such circumstances, one becomes morally undone: the coherence in the moral life that integrity creates is replaced by potentially irremediable fragmentation and chaos. The experience of such extreme fragmentation and chaos is the ethical origin, in our judgment, of intolerable psychological moral distress. In our view, the concept of threats to professional and individual integrity capture the meaning of Laab’s concept of “betrayed” moral integrity (Laabs, 2011, 432). These three impediments incentivize akrasia or moral weakness, in the form of acting on one’s self-interest and not on one’s considered intellectual or moral judgment guided by integrity (Aristotle, 1984). Awareness that one is acting against considered moral judgment, in response to challenges and threats to professional or individual integrity, generates increasingly intense moral distress that manifests psychologically as anxiety, frustration, anger, and dysfunction that result in poor patient care. Awareness that one has become so completely and perhaps irreversibly morally undone, in response to violations of professional or individual integrity, generates worse psychological outcomes, such as burnout, depression, and dangerous patient care because professionals withdraw from the moral dimensions of patient care (Wilkinson 1988; Corley et al., 2001; Meltzer & Huckabay, 2004; Hamric & Blackhall, 2007; Catlin et al., 2008; Epstein & Hamric, 2009; Wiegand & Funk, 2012; Allen et al., 2013). V.  A PHILOSOPHICAL TAXONOMY OF ETHICALLY SIGNIFICANT MORAL DISTRESS The proposed philosophical taxonomy uses the elements described in the previous section to create six categories of ethically significant moral distress articulated in terms of their individually necessary and jointly sufficient

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which professional or individual integrity is threatened. This occurs when one finds oneself in confronting powerful, not-easily-removable or nonremovable impediments that undermine one’s ability to act on and therefore maintain one’s professional or individual integrity. In such circumstances, one is at high risk of becoming morally undone: the coherence in one’s moral life that integrity creates is replaced by moral confusion and dysfunction. In our view, the concept of threats to professional and individual integrity capture the meaning of Laab’s concept of “compromised” moral integrity (Laabs, 2011, 432).



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In an academic hospital ICU a patient with sepsis and multi-organ failure begins to have unstable arrhythmias. The patient’s nurse calls the resident to the bedside to assess. The nurse suggests to the resident that the patient’s family be called in, stating her belief that the patient is dying and not likely to survive much longer. The resident calls the family and reports back to the nurse that the family is on their way to the hospital. As they further discuss the patient’s situation the patient goes into unstable ventricular fibrillation. The nurse and resident immediately begin CPR and are soon joined by numerous interns and residents arriving in response to the CPR event.

Figure 1.  Philosophical taxonomy of ethically significant moral distress

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conditions. These conditions are expressed in terms of (a) the characteristics of three impediments to acting on and maintaining professional or individual integrity: challenges, threats, and violations; and (b) professional and individual integrity. We emphasize that these categories are philosophical and not psychological (fig. 1). We illustrate this taxonomy with two examples. The first pertains to professional integrity and the second to individual integrity. The following clinical scenario, adapted from Epstein and Delgado (2010), illustrates the ethically significant moral distress taxonomy for professional integrity. We have italicized the stages at which challenges and threats to and then violations of professional integrity occur.

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The family arrives on the unit and another nurse quickly directs them away from the patient’s room with CPR in progress to the waiting room and then informs the resident of their arrival. The resident continues to run the code, telling the interns to switch in doing compressions “so everyone gets a chance to learn.” The nurse reminds the resident that the family has arrived and that the patient’s situation, wishes, and utility of CPR should be discussed with them. The resident restates intention to talk with the family but first wants interns to get some practice in with a real code situation.

After another cycle of CPR, the nurse, who has worked with the resident in similar critical situations, restates the need to speak with the family but is dismissed by the resident. The nurse feels powerless in this situation because she does not have the authority to stop the code or change the practices of the resident. She knows that the academic hospital’s mission includes the education and training of residents and interns but recognizes that this conflicts with her professional value of respecting her patient’s autonomy and upholding the patient’s best interest. The nurse’s professional integrity is threatened. The nurse speaks firmly to the resident and threatens to use physical force to stop the CPR until the resident addresses the patient’s family and wishes. The nurse feels powerless watching the practices in the room. The nurse threatens to walk out of the room, refusing to participate in the code, and threatens to call the nurse manager and attending physician. She has never abandoned her clinical duties, commitment to teamwork, or doing what is best for the patient before in similar situations, but now she is at her “wit’s end” as the resuscitation is continued by the resident. The nurse’s professional integrity is violated.

The following clinical scenario was adapted from a real-life situation and illustrates the ethically significant moral distress taxonomy of individual integrity. We have italicized the stages at which challenges and threats to and then violations of professional integrity occur. A group of four residents working in a busy hospital created a pact among themselves while on service together. They all promised to take turns and stay for 3 hours after sign-out to help the on-call resident do admissions, since the majority of patient admissions occurred directly after sign-out. For the past year the residents worked together and appreciated each other’s commitment to the pact without any significant hitches in the schedule. One of the residents named John who pledged into the pact asked the other residents if he could switch out one of his nights because it was his daughter’s 5th birthday and he promised his daughter he would be at home to celebrate with her. The others discussed with him that the initial pact agreement was that everyone promised to stick to their night assignment since a switch would throw off everyone else’s schedule. John felt distressed that he would not be able to uphold his promises as a father and team player. John’s individual integrity is challenged.

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The nurse is deeply distressed by this treatment of the patient and attempts to bring her suggestions to talk to the family to the forefront of the resident’s priorities. The nurse’s professional integrity is challenged.



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John presented different schedule options to the other residents so he could keep his promise to his daughter and residents. However, the other residents firmly told him that he could not leave early on his assigned day or switch out with another resident. The other residents reminded John that this was not an issue last year. John felt his work pact was conflicting with his parental roles. John’s individual integrity is threatened.

VI.  IMPLICATIONS FOR PREVENTION OF AND RESEARCH ON ETHICALLY SIGNIFICANT MORAL DISTRESS The proposed philosophical taxonomy has implications for two key concepts in the moral distress literature, mentioned earlier, moral residue and the crescendo effect (Epstein and Hamric, 2009), the prevention of ethically significant moral distress, and future empirical research. Moral Residue and Crescendo Effect Challenges or threats to professional integrity can occur repeatedly. While each episode may seem manageable, their cumulative effect may not be. Just like the cumulative radiation dosing from repeated exposure to radiation from serial CT imaging, the repeated effects of challenges and threats to integrity create a cumulative moral dosing, making the maintenance of professional and individual integrity progressively more difficult. This cumulative effect is the ethical content of the concept of moral residue (Webster and Bayliss, 2000). Repeated challenges and threats to integrity can also accelerate, causing self-discipline and moral resolve to weaken, resulting in violation of professional or individual integrity. This is the ethical content of the crescendo effect (Epstein and Hamric, 2009). Professional or individual integrity has become so weakened that violations of professional integrity routinely occur. Routine, repeated violations of integrity should be understood to be the most morally toxic form of the crescendo effect. Preventing Ethically Significant Moral Distress The empirical literature on moral distress abundantly documents its debilitating psychological effects. Some investigators have identified how clinicians

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While deciding what other options John had, he was told by the other residents that if he left early on his assigned day or did not show up for his nightly pact assignment, then he would no longer be in the pact and the deal to help him out when on-call would not hold up for him. Knowing that his calls for the next 2 years would be difficult without the pact support, John decided to stay and work his assigned shift. He called his daughter on her birthday from work to tell her he cannot keep his promise to be at home to celebrate her birthday. John’s daughter replied, “It is OK, daddy, I do not cry for you any more.” John’s sense of fatherhood has now changed. John’s individual integrity is violated.

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The Agenda for Future Empirical Research on Ethically Significant Moral Distress The proposed taxonomy of categories of ethically significant moral distress has implications for future empirical research. Qualitative research methods

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respond to these effects, seeking to prevent or ameliorate them (Edwards, McClement, & Read, 2013). A distinctive feature of the proposed taxonomy is that it allows for ethically significant moral distress to occur both when the judgment that one confronts challenges to, threats to, and violations of professional or individual integrity is well founded in reality and when this is not the case. That is, it is enough to think that one confronts such impediments to acting on the knowledge of what one ought to do. The first step in preventing preventable psychological sequelae or psychologically significant moral distress is to test the reliability of one’s judgment. Doing so can also help prevent preventable residue and crescendo effects. Acting on and maintaining professional and individual integrity are essential for clinicians to fulfill their professional responsibilities in patient care, research, education, and adherence to their professional codes of ethics. From the perspective of the proposed philosophical taxonomy, challenges to, threats to, and violations of professional or individual integrity should be understood as progressing along a continuum of ethical significance for professional and individual integrity: from morally concerning (challenges), to dangerous (threats), to corrosive (violations). Progressing along this continuum may reinforce the crescendo effect of moral distress. This progression therefore should be prevented, in order to preserve an organizational culture of professionalism (Chervenak and McCullough, 2005). Preventive ethics comprises organizational policies and practices aimed at the detection of ethical challenges and conflicts early in their development, arresting their early development, and responding rapidly and effectively to them when they occur (with lower frequency; Chervenak and McCullough, 1990). Preventive ethics in the current context is based on the assumption that challenges to professional or individual integrity that progress unchecked to threats and then violations are destructive of an organizational culture of professionalism. The leadership of healthcare organizations—lay and professional alike— should periodically examine organizational policies and practices and critically appraise them vis-à-vis their potential to permit, enable, or even encourage challenges to, threats to, and violations of professional and individual integrity. Leaders should be especially attentive to their willingness to tolerate what should not be tolerated by leaders committed to an organizational culture of professionalism in healthcare: the behavior of often-powerful clinicians that creates, unchecked, challenges to, threats to, and violations of professional and individual integrity of their clinical colleagues.



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VII. CONCLUSION There has been agreement since Jameton’s landmark work three decades ago that moral distress among healthcare professionals is a serious matter. Moral distress is certainly serious psychologically. The philosophical taxonomy of ethically significant moral distress that we have articulated helps to explain why moral distress is serious ethically: challenges to, threats to, and violations of professional and individual integrity are far from morally benign either for individuals or for an organizational culture of professionalism in

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are especially appropriate when an area of concern has not been previously empirically investigated. The philosophical taxonomy presented here suggests the need to conduct qualitative research about such matters as how clinicians form judgments about challenges to, threats to, and violations of professional and individual integrity, for example, by describing how they distinguish, and understand the interactions between, professional and individual integrity. How clinicians experience challenges to, threats to, and violations of professional and individual integrity is a topic ripe for investigations using qualitative research methods. There are also implications of the proposed philosophical taxonomy for measurement research. Hamric recently noted: “The lack of consistency and consensus on the definition of moral distress considerably complicates efforts to study it” (Hamric, 2012, 39). The major tool that has been used in measurement research is the moral distress scale (MDS), introduced by Corley et al. (2001), who were among the first to identify root causes as a measure of moral distress. Hamric, Borchers, and Epstein (2012) amended the MDS and outlined three categories of the root causes of moral distress—clinical situations, internal constraints, and external constraints—resulting in the revised moral distress scale (MDS-R). Measurement research using such tools could be improved by assessing the items in the context of the proposed taxonomy of six categories of ethically significant moral distress. For example, items on the MDS and MDS-R could be evaluated to make explicit which of the six categories each item seeks to measure. Principal component analysis might be used to identify factors, groups of items, the conceptual coherence of which could then be assessed by asking which of the six categories best captures the conceptual coherence of the newly identified factor. The goal of doing so would be the creation of a measurement instrument that has items related to all six categories of ethically significant moral distress. By thus applying the philosophical taxonomy to psychometric tools, investigators may increase their confidence that their measurement research is comprehensively and precisely describing ethically significant moral distress among respondents. Such research will be crucial for evidence-based prevention of ethically significant moral distress by leaders of healthcare organizations.

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health care. Given its potential implications for the quality of patient care, research, and education, ethically significant moral distress should be prevented and, when it occurs, rapidly detected and ameliorated. Deploying the philosophical taxonomy may help foster the ability to fulfill these professionally urgent tasks of clinical ethics. NOTE

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1. In its general meaning, “taxonomy” means a system for classifying items of interest into conceptually distinct categories. Creating classification systems aids subsequent investigation and reflection by identifying important distinctions among the resulting categories, the maintenance of which distinctions prevents conceptual confusion. The phrase “philosophical taxonomy” is used in the philosophical literature to mean a classification of items of philosophical interest into conceptually distinct categories, which classification is thought to aid subsequent philosophical investigation and reflection. Humberstone, for example, defines “philosophical taxonomy” as “the study of classifications imposed upon the totality of statements or propositions in the interest of structuring philosophical discussion” (Humberstone 1996, 121). The philosophical taxonomy proposed here aims to distinguish among and thereby classify the varieties of ethically significant moral distress into conceptually distinct categories. The result of doing so should be to provide philosophical clarity that can then guide subsequent empirical and philosophical investigations of moral distress generally and ethically significant moral distress specifically.



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A philosophical taxonomy of ethically significant moral distress.

Moral distress is one of the core topics of clinical ethics. Although there is a large and growing empirical literature on the psychological aspects o...
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