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Bioethics ISSN 0269-9702 (print); 1467-8519 (online) Volume 29 Number 2 2015 pp 91–97
doi:10.1111/bioe.12064
MORAL DISTRESS AND MORAL CONFLICT IN CLINICAL ETHICS CARINA FOURIE
Keywords moral distress, moral conflict, moral constraint, nursing ethics
ABSTRACT Much research is currently being conducted on health care practitioners’ experiences of moral distress, especially the experience of nurses. What moral distress is, however, is not always clearly delineated and there is some debate as to how it should be defined. This article aims to help to clarify moral distress. My methodology consists primarily of a conceptual analysis, with especial focus on Andrew Jameton’s influential description of moral distress. I will identify and aim to resolve two sources of confusion about moral distress: (1) the compound nature of a narrow definition of distress which stipulates a particular cause, i.e. moral constraint, and (2) the distinction drawn between moral dilemma (or, more accurately, moral conflict) and moral distress, which implies that the two are mutually exclusive. In light of these concerns, I argue that the definition of moral distress should be revised so that moral constraint should not be a necessary condition of moral distress, and that moral conflict should be included as a potential cause of distress. Ultimately, I claim that moral distress should be understood as a specific psychological response to morally challenging situations such as those of moral constraint or moral conflict, or both.
INTRODUCTION Nurses’ experience of moral distress has become a particularly widespread topic of research in nursing ethics. Recently, researchers have also started to consider physicians’ and other hospital staff’s experience of moral distress.1 A systematic review of nurses’ moral distress indicates that it is negatively associated with job retention and concerns have been raised that this form of distress is increasing in prevalence and intensity.2 What moral dis1 S. Kälvemark et al. Living with Conflicts-ethical Dilemmas and Moral Distress in the Health Care System. Soc Sci Med 2004; 58: 1075–1084; R. Førde & O.G. Aasland. Moral Distress Among Norwegian Doctors. J Med Ethics 2008; 34: 521–525. DOI: 10.1136/jme.2007.021246; M.E. Losa Iglesias et al. Comparative Analysis of Moral Distress and Values of the Work Organization Between American and Spanish Podiatric Physicians. J Am Podiatry Assoc 2012; 102: 57–63. 2 D.M. Huffman & L. Rittenmeyer. How Professional Nurses Working in Hospital Environments Experience Moral Distress: A Systematic Review. Crit Care Nurs Clin North Am 2012; 24: 91–100. DOI:
tress is, however, is not always clearly delineated and there is some debate as to how it should be defined.3 A number of authors have called for greater clarity and further conceptual analysis of moral distress.4 This article aims to help to clarify moral distress. I will identify and aim to resolve two primary sources of confusion about moral distress: (1) the compound 10.1016/j.ccell.2012.01.004; W. Austin. Moral Distress and the Contemporary Plight of Health Professionals. HEC Forum 2012; 24: 27–38. DOI: 10.1007/s10730-012-9179-8. 3 J. McCarthy & R. Deady. Moral Distress Reconsidered. Nurs Ethics 2008; 15: 254–262. DOI: 10.1177/0969733007086023; K. Lützén & B. Ewalds Kvist. Moral Distress: A Comparative Analysis of Theoretical Understandings and Inter-Related Concept. HEC Forum 2012; 24: 13–25. DOI: 10.1007/s10730-012-9178-9; C. Varcoe et al. Moral Distress: Tensions as Springboards for Action. HEC Forum 2012; 24: 51–62. DOI: 10.1007/s10730-012-9180-2. 4 McCarthy & Deady, op. cit. note 3; A.B. Hamric. Empirical Research on Moral Distress: Issues, Challenges, and Opportunities. HEC Forum: March 2012; 24: 39–49. DOI: 10.1007/s10730-012-9177-x; B.M. Pauly, C. Varcoe & J. Storch. Framing the Issues: Moral Distress in Health Care. HEC Forum 2012; 24: 1–11. DOI: 10.1007/s10730-012-9176-y.
Address for correspondence: Dr Carina Fourie, Institute of Biomedical Ethics, University of Zurich, Pestalozzistr. 24, Zurich 8032, Switzerland. Email: [email protected] Conflict of interest statement: No conflicts declared © 2013 John Wiley & Sons Ltd
Moral Distress and Moral Conflict in Clinical Ethics nature of a narrow definition of distress which stipulates a particular cause, i.e. moral constraint, and (2) the distinction drawn between moral dilemma (or, more accurately, moral conflict) and moral distress, which implies that the two are mutually exclusive. In light of these concerns, I believe there are two potential alternatives. One is to retain but revise the dominant narrow definition first developed by Andrew Jameton which appears to stipulate that moral constraint is a necessary condition of moral distress.5 I will advocate an alternative, however, which is to use a broader understanding of moral distress according to which moral constraint is not a necessary condition of moral distress. Ultimately, I claim that moral distress should be understood as a specific psychological response to morally challenging situations such as those of moral constraint or moral conflict, or both. This is not offered as a complete definition of distress, however. Such a definition may require further details, such as the negative emotions associated with distress. The methodology of this article consists primarily of a conceptual analysis of moral distress based on an internal critique of Jameton’s description. It also relies on some analysis of the philosophical literature on moral conflict and dilemma, and on the way the term moral distress has been used in the literature on nursing ethics.
1. MORAL DISTRESS VS. MORAL DILEMMA The dominant definition of moral distress in the nursing ethics literature is Jameton’s.6 His definition, revised from an earlier definition, claims that moral distress occurs: ‘when the nurse makes a moral judgment about a case in which he or she is involved and the institution or co-workers make it difficult or impossible for the nurse to act on that judgment’.7 In order to further clarify moral distress, Jameton explicitly distinguishes between moral distress and moral 5
A. Jameton. 1984. Nursing Practice: The Ethical Issues. Prentice-Hall; A. Jameton. Dilemmas of Moral Distress: Moral Responsibility and Nursing Practice. AWHONN’s Clin Issues Perinat Womens Health Nurs 1993; 4: 542–551. 6 Jameton, 1984, op. cit. note 5; Jameton, 1993, op. cit. note 5; Dilemmas of Moral Distress, D.R. Hanna. Moral Distress: The State of the Science. Res Theory Nurs Pract 2004; 18: 73–93, McCarthy & Deady, op. cit. note 3. 7 Jameton, 1993, op. cit. note 5, p. 542. Initially, he defined moral distress as arising ‘when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’ (Jameton, 1984, op. cit. note 5, p. 6). The nursing ethics literature tends to use the original rather than the revised definition. I use the revised definition as it is slightly broader than the original definition; both definitions, however, can be referred to as narrow definitions of moral distress, which I discuss in the next section. By using the broader definition, and claiming that even in its broader version it is still too narrow, my argument will be stronger than if I used the narrowest version.
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dilemma.8 Moral dilemma, he claims, occurs ‘when two (or more) clear moral principles apply, but they support mutually inconsistent courses of action’.9 I will raise the concern that this definition of dilemma is ambiguous later. For the moment, however, one could argue that the distinctions drawn seem to follow from the narrow definition of moral distress – the implication is that if the nurse is able to make a moral judgment, then it cannot be a situation of dilemma. Although Jameton does not state this explicitly, he seems to be claiming that situations of moral distress and moral dilemma are mutually exclusive – if the situation can be described as one of distress, it cannot be one of dilemma and vice versa. To illustrate the distinction, Jameton describes two cases: ‘Overtreatment’ as an example of moral distress and ‘Postoperative Exercise’ as an example of moral dilemma.10 1. Overtreatment (Moral distress): In this case, a severely ill infant is in neonatal intensive care ‘and has poor prospects for a normal life . . . [and] is most likely to be severely retarded, bedridden and in chronic pain.’11 In some similar cases, infants have been taken off the respirator and allowed to die. However, in this case the parents ‘do not seem to understand the situation’ and the physicians pursue aggressive treatment.12 The nurse has to perform treatments which are very painful to the infant, and which he would not perform if it were up to him. Jameton maintains that this is a case of moral distress and not moral dilemma, because the nurse has made a moral judgement – these painful treatments should not be performed. 2. Postoperative exercise (Moral dilemma): In this case, a moral dilemma occurs after a nurse fails to convince a mentally competent patient that she should partake in plenty of postoperative exercise. On the one hand, the nurse believes he should respect the patient’s autonomy – the patient chooses not to engage in exercise and this wish should be respected. On the other hand, the nurse also believes he has a duty to provide the best care in order to improve the patient’s well-being, and he is concerned that in respecting the patient’s autonomy, he is failing to provide his patient with the care necessary to improve her well-being adequately. 8 He also distinguishes between distress and moral uncertainty. However, while this distinction may also pose problems for the narrow definition of distress, I am primarily interested in examining the distinction drawn between dilemma and distress as Jameton particularly highlights this distinction and seems to make it central to his understanding of distress. 9 Jameton, 1984, op. cit. note 5, p. 6. 10 Jameton, 1993, op. cit. note 5, pp. 542–543. 11 Ibid: 543. 12 Ibid.
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2. THE NARROW DEFINITION OF MORAL DISTRESS: THE PSYCHOLOGICAL RESPONSE AND ITS SPECIFIC CAUSE An immediate question that arises when we consider Jameton’s definitions of distress and dilemma is: what kind of phenomenon is moral distress supposed to be? According to Jameton’s definition, moral dilemma appears to be an ethical phenomenon. Its presence can be identified through an ethical analysis which indicates that there are certain morally relevant factors (e.g. principles or duties) that come into conflict with each other. Although Jameton does not make this clear, this ethical phenomenon is distinct from a psychological response that an individual may have in light of this conflict: there may be a moral dilemma with or without the individual experiencing any feelings of conflict.13 A kind of response someone could have towards this kind of conflict is something that, at least in commonsense terms, could be called distress. So, we can distinguish two different phenomena here – the ethical phenomenon of moral dilemma and the psychological phenomenon which might be a response to this dilemma. Jameton’s discussion prompts the question – what kind of phenomenon is moral distress then? Is it a psychological response to an ethical phenomenon? Or is it the phenomenon that prompts the response (like moral dilemma)? Another way of asking this is, is it meant to be an outcome or the possible cause of that outcome? Although Jameton does not make this clear, his discussion of moral distress implies that it is both. Firstly it appears to be a psychological response, as indicated by the commonsense association with the word ‘distress’. Jameton implies this by, for example, referring to the nurse’s experience of moral distress and by discussing some of the feelings associated with distress, e.g. frustration, anger and anxiety.14 Secondly, it also seems to be a specific phenomenon or course of events which leads to a psychological response: the individual knows the morally correct action, and she is prevented from carrying it out, or finds it difficult to carry it out, due to institutional constraints or co-workers. In other words, it seems that Jameton’s understanding of moral distress is that it is a compound phenomenon, which includes both the response and a specific cause. We can refer to this kind of understanding as a narrow definition of moral distress. What is narrow about it is 13
As Philippa Foot puts it ‘For while in many favourite examples the protagonist is torn; like Agamemnon who must sacrifice his daughter to save his campaign . . . it is unlikely that anyone who has to break a promise to see a friend, in order that he may save a life, should be in conflict about what to do.’ P. Foot. 2002. Moral Dilemmas: And Other Topics in Moral Philosophy. New edn. Oxford: Clarendon Press: 38. 14 Jameton, 1993, op. cit. note 5, pp. 543, 544.
precisely that the specific cause is built into the definition – it is a necessary condition of moral distress that this form of moral constraint occurs. Scenarios are ruled out where the individual experiences distress but this form of moral constraint is absent. For example, cases where the individual experiences psychological distress because she is unsure of the morally correct action or she is prevented from carrying out what she believes to be the morally correct action due to other reasons. As we have seen, distress due to moral dilemma is also explicitly ruled out. While Jameton’s definition of moral distress tends to dominate, the literature on nursing ethics includes many criticisms of and variations on Jameton’s original definition.15 However, none of the criticisms of Jameton’s definition thus far raises the particular concerns which are central to this article and thus I hope to provide a unique perspective to help clarify moral distress. In the next section, I will use Jameton’s examples of Overtreatment and Postoperative Exercise to raise concerns about the narrow definition of distress and the distinctions he has drawn between distress and dilemma. Finding solutions to these concerns will help us to understand how to revise the definition of moral distress.
3. CHALLENGING THE NARROW DEFINITION: MORAL CONFLICT AND MORAL DISTRESS If we consider Jameton’s definition of moral dilemma and the examples he uses, we see there is an ambiguity. In this section, I will argue that an analysis of this ambiguity indicates that Postoperative Exercise does not actually seem to be a genuine example of moral dilemma and that both Postoperative Exercise and Overtreatment are actually examples of moral conflict. Overtreatment, I will also argue, may not provide an entirely convincing example of narrow moral distress. Furthermore, I will also indicate that some researchers in the nursing ethics literature seem to assume the narrow definition tacitly, but they are not consistent in sticking to this definition when they discuss the relationship between distress and dilemma, or when they measure moral distress. These problems, I argue, mean that we may need revise or move beyond the narrow definition of moral distress. We can distinguish two notions of moral dilemma – a philosophical and a commonsense or everyday notion.16 The term moral conflict is used in the philosophical 15
McCarthy & Deady, op. cit. note 3; Hamric, op. cit. note 4; Lützén & Kvist, op. cit. note 3; Pauly, Varcoe & Storch, op. cit. note 4. 16 Shelly Kagan. 1998. Normative Ethics. Boulder and Oxford: Westview Press: 182.
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Moral Distress and Moral Conflict in Clinical Ethics literature to describe any situation where normative factors (such as moral principles, values or even certain forms of moral duties) clash and require incompatible actions: This will be because one of the principles picks out certain features of the situation as relevant . . . and the other picks out certain others . . . The problem is to determine which of these principles should be applied to yield a prescription for this particular situation.17 In these cases of conflict, one particular principle or duty should indeed prevail all things considered, and this duty will indicate what the morally correct action should be. However, an individual facing this conflict may feel uncertain about which action to take or may feel distressed because there is more than one important moral factor at play. Here, again, we see the distinction between the ethical phenomenon itself and the psychological response to it. Often this conflict, as an ethical phenomenon, is referred to in everyday terms as ‘moral dilemma’. However, philosophically, a moral dilemma is a very specific kind of moral conflict – one where duties all things considered clash.18 In such a case, there is an inevitable moral failure, as whichever action an individual takes will violate a duty or lead to a failure to uphold a duty all things considered.19 Jameton does not seem to use the term ‘dilemma’ consistently, and it is uncertain whether he really means to indicate dilemma in the philosophical sense or merely moral conflict. On the one hand, by claiming that moral distress occurs when an individual makes a moral judgment about the correct course of action, and that this is not the same as a dilemma, Jameton implies that dilemma is meant in the strict philosophical version. The implication is that one does not make a moral judgment about which course of action should be taken in a dilemma, as there is no judgment to make: any course of action is, to some extent, morally wrong. However, his definition of dilemma appears to be a definition of conflict, not specifically dilemma – ‘when two (or more) clear moral principles apply, but they 17 R.M. Hare. 1978. Moral Conflicts. The Tanner Lecture on Human Values. Available at: http://www.utilitarian.net/singer/by/tanner.pdf. 18 Kagan, op. cit. note 17, p. 182; W. Sinnott-Armstrong. 1988. Moral Dilemmas. Oxford: Blackwell. 19 A duty, all things considered, can be contrasted to a prima facie duty. When prima facie duties clash this constitutes a moral conflict. For example, I have a duty to keep my promises and I have a duty to rescue someone in great danger. A situation arises where these prima facie duties clash – either I can recuse someone who is in great danger or I can keep a promise, but I cannot do both. Usually in this case we would say this is (merely) a moral conflict and not a moral dilemma – one of these prima facie duties will override the other, determining what we should ultimately do, in other words determining our duty all things considered. See, e.g. Hare op. cit. note 17; Kagan op. cit. note 16.
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support mutually inconsistent courses of action.’20 Furthermore, a dilemma in the strict sense does not seem to be at work in the example of Postoperative Exercise. This case seems to be an example of moral conflict, where the values of respect for autonomy and of beneficence could be said to clash. Although they conflict, it seems most likely that we should prioritise one value over the other – which means there is a morally ‘correct’ course of action to follow, and that there is no dilemma in the strict sense. If what Jameton means by dilemma is actually moral conflict, then the distinction between dilemma (i.e. conflict) and distress becomes particularly puzzling. The fact that the nurse has made a moral judgment in a case in no way seems to preclude moral conflict. There could be a moral conflict, the nurse makes a moral judgement, she is then prevented from taking up the course of action that follows from the judgment due to institutional constraints, and she experiences distress. This seems to be something very much like moral distress, but it also includes moral conflict. I will continue the discussion assuming that what Jameton means by dilemma is actually moral conflict. However, it is important to note that either option – whether Jameton actually means dilemma in the strict sense or as conflict – raises important problems. Even if Jameton claims that he is using dilemma in the strict sense, and that he recognises that conflict does not preclude distress, this would still not be satisfactory. Acknowledging that conflict and distress can occur together actually jeopardises the narrow definition of distress, as I will indicate below.21 We have established that Postoperative Exercise does not seem to be an example of moral dilemma but rather of moral conflict. If we examine Overtreatment further we find that this case too could be a case of moral conflict. Consider that in this case it seems feasible that the physicians or parents, or both groups, believe that pursuing treatment and trying to keep the infant alive is the morally correct action. Or perhaps they are not sure which action is morally correct but see value in keeping the infant alive. Or perhaps they are conflicted between moral values – keeping the child alive on the one hand, and reducing its suffering, on the other. If any of these claims are true, then it seems we could have a case of moral conflict. The nurse may be correct about what the morally correct action is; that, however, does not mean 20
Jameton, 1984, op. cit. note 5, p. 6. Furthermore, there is some controversy within the philosophical literature as to whether moral dilemmas, understood philosophically, are either logically or morally possible. B. Williams. 1976. Problems of the Self. Cambridge; Cambridge University Press: 166–186; Hare, op. cit. note 17; A. Donagan. Consistency in Rationalist Moral Systems. J Philos 1984; 81: 291–309; Foot, op. cit. note 13, pp. 37–58, 175–188. 21
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that conflicting values might not be at play. Interestingly then, while Jameton was at pains to draw a distinction between the two cases, what we find is that both could22 be described as cases of moral conflict.23 Once the case of Overtreatment becomes an example of moral conflict, it becomes doubtful that the narrow definition of moral distress actually holds. This is for two reasons. The first reason is simply that Jameton indicates that distress and conflict are mutually exclusive. However, even if he conceded that distress and conflict can occur together, it is still doubtful that this is a case of moral distress because the moral conflict involved makes it difficult for the case to match the narrow definition with its emphasis on moral constraint. According to the narrow definition, the nurse cannot perform the action she judges to be correct, or performs it with difficulty, because of an institutional barrier or a co-worker. Imagine that the parents or physician, or both, genuinely believe that the correct moral action is to try to keep the infant alive using the aggressive treatments to which the nurse objects. It would be inaccurate to say that the nurse is unable to perform what he regards to be the morally correct action merely because of a co-worker or an institutional barrier (such as the hierarchy in place which stipulates that it is the physician who makes final decisions about treatment). Rather, the nurse is unable to perform the correct action because there is disagreement about what the correct course of action is. On top of this moral disagreement, we find the additional burden to the nurse that when there is disagreement between physicians and nurses as to what the right thing is to do, then it is the physician who is likely to have the final say. However, despite this hierarchy, it seems disingenuous to claim that the primary or the only obstacle standing in the way of the nurse performing the action he believes should be performed is an institutional barrier or co-worker. Subsequently, Overtreatment seems doubtful as an example of (narrow) moral distress. Thus what our analysis reveals is that what initially seemed to be two distinguishable examples – one of dilemma, one of distress – actually both seem to be examples of moral conflict and neither of moral distress understood narrowly. What does this signify? This, I argue, is indicative of a problem with having a narrow definition of moral distress, where its specific ethical cause of 22 I say could because it is not clear that there is necessarily moral conflict in this case. If the parents and physicians are clearly mistaken about the case or are driven by unethical motives, then there is probably no genuine moral conflict. 23 Even if one disagreed with my claim that these are moral conflicts and continued to insist on using the term ‘dilemma’, this would not make a difference to my specific argument. The point I want to make would be that both cases can be described as either moral conflict or moral dilemma, and as long as both cases could be the same kind of ethical phenomenon, my concern holds.
constraint is built into the definition, and with the claim that distress and conflict are mutually exclusive. If the definition were revised so that the institutional barrier need not be the primary or only influence on or cause of distress, and if distress and conflict are seen not to be mutually exclusive, then Overtreatment could indeed be an example of moral distress. An advocate of the narrow definition of moral distress could argue that the definition is not at fault but rather the examples are: Overtreatment is simply a poor example of moral distress. There are cases, the advocate could claim, where moral distress defined narrowly is indeed clear. Although I agree it would be possible to create examples of narrowly defined moral distress, and even to find real cases of it in practice, I do not believe that Overtreatment is merely a bad example of moral distress. My claim that the problem lies rather with the definition of moral distress and its distinction from conflict is reinforced by confusion over moral distress in the literature. Many researchers simply ignore the distinction that Jameton draws between distress and dilemma. For example, Kälvemark et al. use the narrow definition of moral distress (while arguing that it should be expanded to include legal constraints), but ignore Jameton’s distinction between situations of distress and dilemma.24 Indeed, in contrast to Jameton (although seemingly without explicit recognition that there is a contrast) they claim that ‘Stress related to ethical dilemmas is usually referred to as “moral distress” ’.25 I think their disregard of this distinction is indicative of the fact that this distinction is problematic to draw. However, it is also not a solution to do as they do – to maintain the narrow definition of moral distress while ignoring the distinction between distress and conflict. As we have seen from the discussion above, if moral disagreement occurs due to moral conflict we cannot say that distress has developed due to an institutional constraint (or merely due to this constraint). Thus according to the narrow definition of moral distress we cannot say that distress has occurred at all. Kälvemark et al. have the right instinct here which is that we should not be drawing such a sharp distinction between cases of distress and cases of conflict; the two can go together.26 However, it seems likely that we need to go further than simply disregarding this distinction – we may need to adopt an understanding of distress that goes beyond the narrow definition. Furthermore, what is actually being measured by empirical studies does not necessarily conform to the narrow definition of moral distress. For example, two recent studies claim to be measuring moral distress, but 24 25 26
Kälvemark et al., op. cit. note 1. Ibid: 1076. Ibid.
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Moral Distress and Moral Conflict in Clinical Ethics both studies concentrate on what they explicitly identify as cases of moral conflict.27 If we accepted the narrow definition of moral distress we would have to ignore their studies, at least as studies of the phenomenon of moral distress. However, again, it seems more likely an explanation that this is indicative of a problem with the definition of moral distress rather than that these studies are not measuring the ‘correct’ phenomenon.
4. WHAT IS MORAL DISTRESS? 4.1 Decoupling constraint from distress My analysis has raised challenges to the narrow definition of moral distress. What is the solution? I believe there could be two alternatives, although I find one more convincing than the other, and will discuss why in this section. The first solution, which is not my preference, is to retain the narrow definition of distress in terms of its emphasis on constraint. Thus moral constraint would continue to be a necessary condition for moral distress. However, in light of my discussion, I believe that the definition would still have to be revised – moral conflict and distress should not be considered to be mutually exclusive. At the very least we need to expand the definition of moral distress to include scope for conflict. If this alternative is adopted, then there are will be some gaps in the literature on moral distress and more generally in clinical ethics that will need to be addressed. If we continue using constraint as a necessary condition of moral distress, there is a risk of neglecting cases of distress arising from morally relevant causes other than constraint. At the least, if we are interested in health care practitioners’ morally relevant experiences of distress, we need to acknowledge there are forms of distress which cannot be linked to constraint but which may be caused by moral challenges such as conflict or uncertainty. We should also be concerned to analyse and to conduct research on these other forms of distress. Yet, generally in the literature on nursing ethics, no name has been suggested for this other form of ‘moral’ distress and no attempts are made to emphasise its importance. If we insisted on defining distress according to constraint (and actually followed this through) there would thus be a large gap in the literature. However, the very fact that there is no attempt to identify other ‘forms’ of moral distress is, I believe, actually related to the failure to adhere to the narrow defini27
M. Lazzarin, A. Biondi, & St. Di Mauro. Moral Distress in Nurses in Oncology and Haematology Units. Nurs Ethics 2012; 19: 183–195. DOI: 10.1177/0969733011416840; J.W. Kayser, D. Nault & G. Ostiguy. Resolving Moral Distress When Caring for Patients Who Smoke While Using Home Oxygen Therapy. Home Healthc Nurse 2012; 30: 208–215. DOI: 10.1097/NHH.0b013e31824c2892. Lazzarin et al. use the term ‘dilemma’, rather than conflict.
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tion and the confusion over what distress is. As discussed in the previous section, the problem is not that researchers simply stick to the narrow definition of moral distress and then neglect other forms of distress. It is rather that they might claim to adopt what seems to be the narrow definition but may not actually follow through with it, and are actually measuring a notion of distress that goes beyond constraint. This is one of the reasons why I endorse a second potential solution: when it comes to defining moral distress, there need be no constraint. This specific cause of distress, while I acknowledge it is of significance, should be decoupled from the definition of moral distress. Why does it seem so important to highlight this specific cause, moral constraint, as part of moral distress? One can see that the notion of constraint is likely to be particularly significant in a clinical setting. It is especially apt in highlighting the conditions in which nurses, who are often low down on the decision-making hierarchy, are likely to work. While moral constraint may be particularly relevant for nurses, it seems clear that other hospital staff, including physicians, could also be vulnerable to the experience of moral constraint, particularly perhaps due to economic and resource constraints that they may feel hampers their treatment of patients.28 Constraint is so significant a concern that many in nursing ethics implicitly accept it as a necessary condition of distress, although some argue it should be expanded to include other forms of constraint not specified by Jameton. Kälvemark et al., for example, claim that Jameton’s definition should be expanded to include legal constraints, while McCarthy and Deady argue that moral distress should be understood as ‘an umbrella concept that captures the range of experiences of individuals who are morally constrained’.29 However, although I can see the importance of investigating moral constraint in a clinical setting, when it comes to defining moral distress and understanding its relationship with moral conflict, we have good reason to be cautious about restricting distress to constraint. One can acknowledge that moral constraint is a particular problem for nurses but without conceding that it should be built into a definition of distress. If there are reasons for building it into the definition then there would be another gap in the literature on nursing ethics: reasons are not provided why moral distress should be seen as a compound phenomenon incorporating the specific ethical cause of constraint. Additionally, there seem to be good reasons why constraint should not be built into the definition of distress. The first of these reasons we have already discussed in the previous section. In cases such as that of Overtreatment 28
Førde & Aasland, op. cit. note 1; Losa Iglesias et al., op. cit. note 1. Kälvemark et al., op. cit. note 1; McCarthy & Deady, op. cit. note 3, p. 254. 29
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where constraint and conflict could occur simultaneously, a definition of moral distress, which makes constraint central to distress, seems to distort the reality of the situation. While constraint may be present and its significance should not be under-estimated, as discussed, the case does not seem to be one which is accurately portrayed as being primarily about constraint: it is not simply that other people are arbitrarily or unfairly standing in the nurse’s way but that they genuinely disagree with the nurse on a moral basis. Furthermore, if we limit distress to cases of constraint we may be dismissing the real-life experiences of many nurses. In practice, nurses and researchers on the topic often refer to certain cases as being examples of moral distress, but moral constraint is not necessarily present and distress may be due to, for example, a lack of knowledge.30 Of course, it is possible that at times the wrong term is being used. For example, one could claim to be experiencing moral distress, while actually experiencing psychological distress with no morally relevant cause.31 However, if we insist on making constraint a necessary condition of moral distress, we will be insisting that one would even be making a mistake in describing as moral distress cases of distress with morally relevant causes, such as moral conflict or moral uncertainty, where these occur without the presence of constraint.
4.2 An expanded definition of moral distress These problems with the narrow definition of distress discussed above indicate that simply insisting that moral distress and conflict should not be considered to be mutually exclusive may not be adequate for clarifying the notion of distress. I would recommend that the narrow definition of distress should no longer be implicitly associated with both the psychological response and the specific ethical cause of moral constraint. Of course, moral distress cannot simply be equivalent to psychological distress either. We need to specify that this form of distress has ‘moral’ causes. Thus I recommend that we substitute the narrow definition with this basis for a definition that allows a broader range of causes: Moral distress is a psychological response to morally challenging situations such as those of moral constraint or moral conflict, or both.32 This definition is only a starting point: it is an adequate response to the particular problems with the narrow definition and the distinction between conflict and distress 30
Hamric, op. cit. note 4. Lützén & Kvist, op. cit. note 3, have found cases of this. 32 I do not claim that this is an entirely new definition of moral distress. This paper is intended as a specific explanation and defence of this definition, in contrast to the influential narrow versions. 31
that I consider in this paper. There may be a need to include further details in this definition, such as examples of what kind of psychological responses, e.g. guilt or anxiety, tend to be experienced as part of moral distress. Using this starting point, the different causes of distress could be used to classify different forms of moral distress. For example, one could refer to moral-constraint distress or moral-conflict distress keeping in mind that some situations could be examples of both of these forms of distress (and that conflict and constraint are not intended to be exhaustive of the possible influences on distress). In this way, if some researchers chose to focus on distress caused by constraint, they could specify this without at the same time indicating, as the narrow definition does, that this is the only form of moral distress. Consider how this definition may be applied to Jameton’s examples of Postoperative Exercise and Overtreatment. If the nurse in each one of these cases does not suffer psychological distress in response to these morally challenging situations then neither case would be one of moral distress. Postoperative Exercise, however, is still likely to be a case of moral conflict and Overtreatment of moral conflict and moral constraint, even if no distress is experienced. If the nurse suffers distress in either of these cases then we can refer to them as cases of moral distress and more specifically as moralconflict distress in the case of Postoperative Exercise and potentially both moral-conflict and moral-constraint distress in the case of Overtreatment.
Acknowledgements I would like to thank Jan-Christoph Heilinger and Verina Wild for valuable comments that have helped me to improve this article. I would also like to thank members of the IDoC project (Assessing the impact of Diagnosis-Related Groups on patient care and professional practice); members of the Institute of Biomedical Ethics, Zurich; and Daniel Strech for their feedback and suggestions. This article was prepared as part of the IDoC project. It does not intend to reflect the views of the project as whole. The project aims to provide empirical data on the impact of DRGs in Switzerland; to provide a critical analysis of the relevant ethical and legal issues; and to develop a set of tools for the long-term evaluation and monitoring of the impact on ethically relevant aspects. It comprises of 5 sub-projects conducted in the disciplines of Medical Ethics (Project Leaders: Nikola Biller-Andorno and Verina Wild, University of Zurich), Law (Project Leaders: Bernice Elger, University of Basel, and Thomas Gächter, University of Zurich), Nursing Sciences (Project Leaders: Rebecca Spirig, University Hospital Zurich), Health Services Research I (Project Leader: Dragana Radovanovic, University of Zurich), and Health Services Research II (Project Leader: Bernard Burnand and John-Paul Vader, University of Lausanne). The IDoC project has been undertaken with financial support from the Swiss National Science Foundation (the SNSF). Carina Fourie is a Post-Doctoral Fellow at the Institute of Biomedical Ethics, University of Zurich. Her research interests include social justice and equality, population level bioethics, and the fairness of health care reform. She has a PhD in Political and Moral Philosophy from University College London.
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Bioethics ISSN 0269-9702 (print); 1467-8519 (online) Volume 29 Number 2 2015 pp 91–97
doi:10.1111/bioe.12064
MORAL DISTRESS AND MORAL CONFLICT IN CLINICAL ETHICS CARINA FOURIE
Keywords moral distress, moral conflict, moral constraint, nursing ethics
ABSTRACT Much research is currently being conducted on health care practitioners’ experiences of moral distress, especially the experience of nurses. What moral distress is, however, is not always clearly delineated and there is some debate as to how it should be defined. This article aims to help to clarify moral distress. My methodology consists primarily of a conceptual analysis, with especial focus on Andrew Jameton’s influential description of moral distress. I will identify and aim to resolve two sources of confusion about moral distress: (1) the compound nature of a narrow definition of distress which stipulates a particular cause, i.e. moral constraint, and (2) the distinction drawn between moral dilemma (or, more accurately, moral conflict) and moral distress, which implies that the two are mutually exclusive. In light of these concerns, I argue that the definition of moral distress should be revised so that moral constraint should not be a necessary condition of moral distress, and that moral conflict should be included as a potential cause of distress. Ultimately, I claim that moral distress should be understood as a specific psychological response to morally challenging situations such as those of moral constraint or moral conflict, or both.
INTRODUCTION Nurses’ experience of moral distress has become a particularly widespread topic of research in nursing ethics. Recently, researchers have also started to consider physicians’ and other hospital staff’s experience of moral distress.1 A systematic review of nurses’ moral distress indicates that it is negatively associated with job retention and concerns have been raised that this form of distress is increasing in prevalence and intensity.2 What moral dis1 S. Kälvemark et al. Living with Conflicts-ethical Dilemmas and Moral Distress in the Health Care System. Soc Sci Med 2004; 58: 1075–1084; R. Førde & O.G. Aasland. Moral Distress Among Norwegian Doctors. J Med Ethics 2008; 34: 521–525. DOI: 10.1136/jme.2007.021246; M.E. Losa Iglesias et al. Comparative Analysis of Moral Distress and Values of the Work Organization Between American and Spanish Podiatric Physicians. J Am Podiatry Assoc 2012; 102: 57–63. 2 D.M. Huffman & L. Rittenmeyer. How Professional Nurses Working in Hospital Environments Experience Moral Distress: A Systematic Review. Crit Care Nurs Clin North Am 2012; 24: 91–100. DOI:
tress is, however, is not always clearly delineated and there is some debate as to how it should be defined.3 A number of authors have called for greater clarity and further conceptual analysis of moral distress.4 This article aims to help to clarify moral distress. I will identify and aim to resolve two primary sources of confusion about moral distress: (1) the compound 10.1016/j.ccell.2012.01.004; W. Austin. Moral Distress and the Contemporary Plight of Health Professionals. HEC Forum 2012; 24: 27–38. DOI: 10.1007/s10730-012-9179-8. 3 J. McCarthy & R. Deady. Moral Distress Reconsidered. Nurs Ethics 2008; 15: 254–262. DOI: 10.1177/0969733007086023; K. Lützén & B. Ewalds Kvist. Moral Distress: A Comparative Analysis of Theoretical Understandings and Inter-Related Concept. HEC Forum 2012; 24: 13–25. DOI: 10.1007/s10730-012-9178-9; C. Varcoe et al. Moral Distress: Tensions as Springboards for Action. HEC Forum 2012; 24: 51–62. DOI: 10.1007/s10730-012-9180-2. 4 McCarthy & Deady, op. cit. note 3; A.B. Hamric. Empirical Research on Moral Distress: Issues, Challenges, and Opportunities. HEC Forum: March 2012; 24: 39–49. DOI: 10.1007/s10730-012-9177-x; B.M. Pauly, C. Varcoe & J. Storch. Framing the Issues: Moral Distress in Health Care. HEC Forum 2012; 24: 1–11. DOI: 10.1007/s10730-012-9176-y.
Address for correspondence: Dr Carina Fourie, Institute of Biomedical Ethics, University of Zurich, Pestalozzistr. 24, Zurich 8032, Switzerland. Email: [email protected] Conflict of interest statement: No conflicts declared © 2013 John Wiley & Sons Ltd
Moral Distress and Moral Conflict in Clinical Ethics nature of a narrow definition of distress which stipulates a particular cause, i.e. moral constraint, and (2) the distinction drawn between moral dilemma (or, more accurately, moral conflict) and moral distress, which implies that the two are mutually exclusive. In light of these concerns, I believe there are two potential alternatives. One is to retain but revise the dominant narrow definition first developed by Andrew Jameton which appears to stipulate that moral constraint is a necessary condition of moral distress.5 I will advocate an alternative, however, which is to use a broader understanding of moral distress according to which moral constraint is not a necessary condition of moral distress. Ultimately, I claim that moral distress should be understood as a specific psychological response to morally challenging situations such as those of moral constraint or moral conflict, or both. This is not offered as a complete definition of distress, however. Such a definition may require further details, such as the negative emotions associated with distress. The methodology of this article consists primarily of a conceptual analysis of moral distress based on an internal critique of Jameton’s description. It also relies on some analysis of the philosophical literature on moral conflict and dilemma, and on the way the term moral distress has been used in the literature on nursing ethics.
1. MORAL DISTRESS VS. MORAL DILEMMA The dominant definition of moral distress in the nursing ethics literature is Jameton’s.6 His definition, revised from an earlier definition, claims that moral distress occurs: ‘when the nurse makes a moral judgment about a case in which he or she is involved and the institution or co-workers make it difficult or impossible for the nurse to act on that judgment’.7 In order to further clarify moral distress, Jameton explicitly distinguishes between moral distress and moral 5
A. Jameton. 1984. Nursing Practice: The Ethical Issues. Prentice-Hall; A. Jameton. Dilemmas of Moral Distress: Moral Responsibility and Nursing Practice. AWHONN’s Clin Issues Perinat Womens Health Nurs 1993; 4: 542–551. 6 Jameton, 1984, op. cit. note 5; Jameton, 1993, op. cit. note 5; Dilemmas of Moral Distress, D.R. Hanna. Moral Distress: The State of the Science. Res Theory Nurs Pract 2004; 18: 73–93, McCarthy & Deady, op. cit. note 3. 7 Jameton, 1993, op. cit. note 5, p. 542. Initially, he defined moral distress as arising ‘when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’ (Jameton, 1984, op. cit. note 5, p. 6). The nursing ethics literature tends to use the original rather than the revised definition. I use the revised definition as it is slightly broader than the original definition; both definitions, however, can be referred to as narrow definitions of moral distress, which I discuss in the next section. By using the broader definition, and claiming that even in its broader version it is still too narrow, my argument will be stronger than if I used the narrowest version.
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dilemma.8 Moral dilemma, he claims, occurs ‘when two (or more) clear moral principles apply, but they support mutually inconsistent courses of action’.9 I will raise the concern that this definition of dilemma is ambiguous later. For the moment, however, one could argue that the distinctions drawn seem to follow from the narrow definition of moral distress – the implication is that if the nurse is able to make a moral judgment, then it cannot be a situation of dilemma. Although Jameton does not state this explicitly, he seems to be claiming that situations of moral distress and moral dilemma are mutually exclusive – if the situation can be described as one of distress, it cannot be one of dilemma and vice versa. To illustrate the distinction, Jameton describes two cases: ‘Overtreatment’ as an example of moral distress and ‘Postoperative Exercise’ as an example of moral dilemma.10 1. Overtreatment (Moral distress): In this case, a severely ill infant is in neonatal intensive care ‘and has poor prospects for a normal life . . . [and] is most likely to be severely retarded, bedridden and in chronic pain.’11 In some similar cases, infants have been taken off the respirator and allowed to die. However, in this case the parents ‘do not seem to understand the situation’ and the physicians pursue aggressive treatment.12 The nurse has to perform treatments which are very painful to the infant, and which he would not perform if it were up to him. Jameton maintains that this is a case of moral distress and not moral dilemma, because the nurse has made a moral judgement – these painful treatments should not be performed. 2. Postoperative exercise (Moral dilemma): In this case, a moral dilemma occurs after a nurse fails to convince a mentally competent patient that she should partake in plenty of postoperative exercise. On the one hand, the nurse believes he should respect the patient’s autonomy – the patient chooses not to engage in exercise and this wish should be respected. On the other hand, the nurse also believes he has a duty to provide the best care in order to improve the patient’s well-being, and he is concerned that in respecting the patient’s autonomy, he is failing to provide his patient with the care necessary to improve her well-being adequately. 8 He also distinguishes between distress and moral uncertainty. However, while this distinction may also pose problems for the narrow definition of distress, I am primarily interested in examining the distinction drawn between dilemma and distress as Jameton particularly highlights this distinction and seems to make it central to his understanding of distress. 9 Jameton, 1984, op. cit. note 5, p. 6. 10 Jameton, 1993, op. cit. note 5, pp. 542–543. 11 Ibid: 543. 12 Ibid.
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2. THE NARROW DEFINITION OF MORAL DISTRESS: THE PSYCHOLOGICAL RESPONSE AND ITS SPECIFIC CAUSE An immediate question that arises when we consider Jameton’s definitions of distress and dilemma is: what kind of phenomenon is moral distress supposed to be? According to Jameton’s definition, moral dilemma appears to be an ethical phenomenon. Its presence can be identified through an ethical analysis which indicates that there are certain morally relevant factors (e.g. principles or duties) that come into conflict with each other. Although Jameton does not make this clear, this ethical phenomenon is distinct from a psychological response that an individual may have in light of this conflict: there may be a moral dilemma with or without the individual experiencing any feelings of conflict.13 A kind of response someone could have towards this kind of conflict is something that, at least in commonsense terms, could be called distress. So, we can distinguish two different phenomena here – the ethical phenomenon of moral dilemma and the psychological phenomenon which might be a response to this dilemma. Jameton’s discussion prompts the question – what kind of phenomenon is moral distress then? Is it a psychological response to an ethical phenomenon? Or is it the phenomenon that prompts the response (like moral dilemma)? Another way of asking this is, is it meant to be an outcome or the possible cause of that outcome? Although Jameton does not make this clear, his discussion of moral distress implies that it is both. Firstly it appears to be a psychological response, as indicated by the commonsense association with the word ‘distress’. Jameton implies this by, for example, referring to the nurse’s experience of moral distress and by discussing some of the feelings associated with distress, e.g. frustration, anger and anxiety.14 Secondly, it also seems to be a specific phenomenon or course of events which leads to a psychological response: the individual knows the morally correct action, and she is prevented from carrying it out, or finds it difficult to carry it out, due to institutional constraints or co-workers. In other words, it seems that Jameton’s understanding of moral distress is that it is a compound phenomenon, which includes both the response and a specific cause. We can refer to this kind of understanding as a narrow definition of moral distress. What is narrow about it is 13
As Philippa Foot puts it ‘For while in many favourite examples the protagonist is torn; like Agamemnon who must sacrifice his daughter to save his campaign . . . it is unlikely that anyone who has to break a promise to see a friend, in order that he may save a life, should be in conflict about what to do.’ P. Foot. 2002. Moral Dilemmas: And Other Topics in Moral Philosophy. New edn. Oxford: Clarendon Press: 38. 14 Jameton, 1993, op. cit. note 5, pp. 543, 544.
precisely that the specific cause is built into the definition – it is a necessary condition of moral distress that this form of moral constraint occurs. Scenarios are ruled out where the individual experiences distress but this form of moral constraint is absent. For example, cases where the individual experiences psychological distress because she is unsure of the morally correct action or she is prevented from carrying out what she believes to be the morally correct action due to other reasons. As we have seen, distress due to moral dilemma is also explicitly ruled out. While Jameton’s definition of moral distress tends to dominate, the literature on nursing ethics includes many criticisms of and variations on Jameton’s original definition.15 However, none of the criticisms of Jameton’s definition thus far raises the particular concerns which are central to this article and thus I hope to provide a unique perspective to help clarify moral distress. In the next section, I will use Jameton’s examples of Overtreatment and Postoperative Exercise to raise concerns about the narrow definition of distress and the distinctions he has drawn between distress and dilemma. Finding solutions to these concerns will help us to understand how to revise the definition of moral distress.
3. CHALLENGING THE NARROW DEFINITION: MORAL CONFLICT AND MORAL DISTRESS If we consider Jameton’s definition of moral dilemma and the examples he uses, we see there is an ambiguity. In this section, I will argue that an analysis of this ambiguity indicates that Postoperative Exercise does not actually seem to be a genuine example of moral dilemma and that both Postoperative Exercise and Overtreatment are actually examples of moral conflict. Overtreatment, I will also argue, may not provide an entirely convincing example of narrow moral distress. Furthermore, I will also indicate that some researchers in the nursing ethics literature seem to assume the narrow definition tacitly, but they are not consistent in sticking to this definition when they discuss the relationship between distress and dilemma, or when they measure moral distress. These problems, I argue, mean that we may need revise or move beyond the narrow definition of moral distress. We can distinguish two notions of moral dilemma – a philosophical and a commonsense or everyday notion.16 The term moral conflict is used in the philosophical 15
McCarthy & Deady, op. cit. note 3; Hamric, op. cit. note 4; Lützén & Kvist, op. cit. note 3; Pauly, Varcoe & Storch, op. cit. note 4. 16 Shelly Kagan. 1998. Normative Ethics. Boulder and Oxford: Westview Press: 182.
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Moral Distress and Moral Conflict in Clinical Ethics literature to describe any situation where normative factors (such as moral principles, values or even certain forms of moral duties) clash and require incompatible actions: This will be because one of the principles picks out certain features of the situation as relevant . . . and the other picks out certain others . . . The problem is to determine which of these principles should be applied to yield a prescription for this particular situation.17 In these cases of conflict, one particular principle or duty should indeed prevail all things considered, and this duty will indicate what the morally correct action should be. However, an individual facing this conflict may feel uncertain about which action to take or may feel distressed because there is more than one important moral factor at play. Here, again, we see the distinction between the ethical phenomenon itself and the psychological response to it. Often this conflict, as an ethical phenomenon, is referred to in everyday terms as ‘moral dilemma’. However, philosophically, a moral dilemma is a very specific kind of moral conflict – one where duties all things considered clash.18 In such a case, there is an inevitable moral failure, as whichever action an individual takes will violate a duty or lead to a failure to uphold a duty all things considered.19 Jameton does not seem to use the term ‘dilemma’ consistently, and it is uncertain whether he really means to indicate dilemma in the philosophical sense or merely moral conflict. On the one hand, by claiming that moral distress occurs when an individual makes a moral judgment about the correct course of action, and that this is not the same as a dilemma, Jameton implies that dilemma is meant in the strict philosophical version. The implication is that one does not make a moral judgment about which course of action should be taken in a dilemma, as there is no judgment to make: any course of action is, to some extent, morally wrong. However, his definition of dilemma appears to be a definition of conflict, not specifically dilemma – ‘when two (or more) clear moral principles apply, but they 17 R.M. Hare. 1978. Moral Conflicts. The Tanner Lecture on Human Values. Available at: http://www.utilitarian.net/singer/by/tanner.pdf. 18 Kagan, op. cit. note 17, p. 182; W. Sinnott-Armstrong. 1988. Moral Dilemmas. Oxford: Blackwell. 19 A duty, all things considered, can be contrasted to a prima facie duty. When prima facie duties clash this constitutes a moral conflict. For example, I have a duty to keep my promises and I have a duty to rescue someone in great danger. A situation arises where these prima facie duties clash – either I can recuse someone who is in great danger or I can keep a promise, but I cannot do both. Usually in this case we would say this is (merely) a moral conflict and not a moral dilemma – one of these prima facie duties will override the other, determining what we should ultimately do, in other words determining our duty all things considered. See, e.g. Hare op. cit. note 17; Kagan op. cit. note 16.
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support mutually inconsistent courses of action.’20 Furthermore, a dilemma in the strict sense does not seem to be at work in the example of Postoperative Exercise. This case seems to be an example of moral conflict, where the values of respect for autonomy and of beneficence could be said to clash. Although they conflict, it seems most likely that we should prioritise one value over the other – which means there is a morally ‘correct’ course of action to follow, and that there is no dilemma in the strict sense. If what Jameton means by dilemma is actually moral conflict, then the distinction between dilemma (i.e. conflict) and distress becomes particularly puzzling. The fact that the nurse has made a moral judgment in a case in no way seems to preclude moral conflict. There could be a moral conflict, the nurse makes a moral judgement, she is then prevented from taking up the course of action that follows from the judgment due to institutional constraints, and she experiences distress. This seems to be something very much like moral distress, but it also includes moral conflict. I will continue the discussion assuming that what Jameton means by dilemma is actually moral conflict. However, it is important to note that either option – whether Jameton actually means dilemma in the strict sense or as conflict – raises important problems. Even if Jameton claims that he is using dilemma in the strict sense, and that he recognises that conflict does not preclude distress, this would still not be satisfactory. Acknowledging that conflict and distress can occur together actually jeopardises the narrow definition of distress, as I will indicate below.21 We have established that Postoperative Exercise does not seem to be an example of moral dilemma but rather of moral conflict. If we examine Overtreatment further we find that this case too could be a case of moral conflict. Consider that in this case it seems feasible that the physicians or parents, or both groups, believe that pursuing treatment and trying to keep the infant alive is the morally correct action. Or perhaps they are not sure which action is morally correct but see value in keeping the infant alive. Or perhaps they are conflicted between moral values – keeping the child alive on the one hand, and reducing its suffering, on the other. If any of these claims are true, then it seems we could have a case of moral conflict. The nurse may be correct about what the morally correct action is; that, however, does not mean 20
Jameton, 1984, op. cit. note 5, p. 6. Furthermore, there is some controversy within the philosophical literature as to whether moral dilemmas, understood philosophically, are either logically or morally possible. B. Williams. 1976. Problems of the Self. Cambridge; Cambridge University Press: 166–186; Hare, op. cit. note 17; A. Donagan. Consistency in Rationalist Moral Systems. J Philos 1984; 81: 291–309; Foot, op. cit. note 13, pp. 37–58, 175–188. 21
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that conflicting values might not be at play. Interestingly then, while Jameton was at pains to draw a distinction between the two cases, what we find is that both could22 be described as cases of moral conflict.23 Once the case of Overtreatment becomes an example of moral conflict, it becomes doubtful that the narrow definition of moral distress actually holds. This is for two reasons. The first reason is simply that Jameton indicates that distress and conflict are mutually exclusive. However, even if he conceded that distress and conflict can occur together, it is still doubtful that this is a case of moral distress because the moral conflict involved makes it difficult for the case to match the narrow definition with its emphasis on moral constraint. According to the narrow definition, the nurse cannot perform the action she judges to be correct, or performs it with difficulty, because of an institutional barrier or a co-worker. Imagine that the parents or physician, or both, genuinely believe that the correct moral action is to try to keep the infant alive using the aggressive treatments to which the nurse objects. It would be inaccurate to say that the nurse is unable to perform what he regards to be the morally correct action merely because of a co-worker or an institutional barrier (such as the hierarchy in place which stipulates that it is the physician who makes final decisions about treatment). Rather, the nurse is unable to perform the correct action because there is disagreement about what the correct course of action is. On top of this moral disagreement, we find the additional burden to the nurse that when there is disagreement between physicians and nurses as to what the right thing is to do, then it is the physician who is likely to have the final say. However, despite this hierarchy, it seems disingenuous to claim that the primary or the only obstacle standing in the way of the nurse performing the action he believes should be performed is an institutional barrier or co-worker. Subsequently, Overtreatment seems doubtful as an example of (narrow) moral distress. Thus what our analysis reveals is that what initially seemed to be two distinguishable examples – one of dilemma, one of distress – actually both seem to be examples of moral conflict and neither of moral distress understood narrowly. What does this signify? This, I argue, is indicative of a problem with having a narrow definition of moral distress, where its specific ethical cause of 22 I say could because it is not clear that there is necessarily moral conflict in this case. If the parents and physicians are clearly mistaken about the case or are driven by unethical motives, then there is probably no genuine moral conflict. 23 Even if one disagreed with my claim that these are moral conflicts and continued to insist on using the term ‘dilemma’, this would not make a difference to my specific argument. The point I want to make would be that both cases can be described as either moral conflict or moral dilemma, and as long as both cases could be the same kind of ethical phenomenon, my concern holds.
constraint is built into the definition, and with the claim that distress and conflict are mutually exclusive. If the definition were revised so that the institutional barrier need not be the primary or only influence on or cause of distress, and if distress and conflict are seen not to be mutually exclusive, then Overtreatment could indeed be an example of moral distress. An advocate of the narrow definition of moral distress could argue that the definition is not at fault but rather the examples are: Overtreatment is simply a poor example of moral distress. There are cases, the advocate could claim, where moral distress defined narrowly is indeed clear. Although I agree it would be possible to create examples of narrowly defined moral distress, and even to find real cases of it in practice, I do not believe that Overtreatment is merely a bad example of moral distress. My claim that the problem lies rather with the definition of moral distress and its distinction from conflict is reinforced by confusion over moral distress in the literature. Many researchers simply ignore the distinction that Jameton draws between distress and dilemma. For example, Kälvemark et al. use the narrow definition of moral distress (while arguing that it should be expanded to include legal constraints), but ignore Jameton’s distinction between situations of distress and dilemma.24 Indeed, in contrast to Jameton (although seemingly without explicit recognition that there is a contrast) they claim that ‘Stress related to ethical dilemmas is usually referred to as “moral distress” ’.25 I think their disregard of this distinction is indicative of the fact that this distinction is problematic to draw. However, it is also not a solution to do as they do – to maintain the narrow definition of moral distress while ignoring the distinction between distress and conflict. As we have seen from the discussion above, if moral disagreement occurs due to moral conflict we cannot say that distress has developed due to an institutional constraint (or merely due to this constraint). Thus according to the narrow definition of moral distress we cannot say that distress has occurred at all. Kälvemark et al. have the right instinct here which is that we should not be drawing such a sharp distinction between cases of distress and cases of conflict; the two can go together.26 However, it seems likely that we need to go further than simply disregarding this distinction – we may need to adopt an understanding of distress that goes beyond the narrow definition. Furthermore, what is actually being measured by empirical studies does not necessarily conform to the narrow definition of moral distress. For example, two recent studies claim to be measuring moral distress, but 24 25 26
Kälvemark et al., op. cit. note 1. Ibid: 1076. Ibid.
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Moral Distress and Moral Conflict in Clinical Ethics both studies concentrate on what they explicitly identify as cases of moral conflict.27 If we accepted the narrow definition of moral distress we would have to ignore their studies, at least as studies of the phenomenon of moral distress. However, again, it seems more likely an explanation that this is indicative of a problem with the definition of moral distress rather than that these studies are not measuring the ‘correct’ phenomenon.
4. WHAT IS MORAL DISTRESS? 4.1 Decoupling constraint from distress My analysis has raised challenges to the narrow definition of moral distress. What is the solution? I believe there could be two alternatives, although I find one more convincing than the other, and will discuss why in this section. The first solution, which is not my preference, is to retain the narrow definition of distress in terms of its emphasis on constraint. Thus moral constraint would continue to be a necessary condition for moral distress. However, in light of my discussion, I believe that the definition would still have to be revised – moral conflict and distress should not be considered to be mutually exclusive. At the very least we need to expand the definition of moral distress to include scope for conflict. If this alternative is adopted, then there are will be some gaps in the literature on moral distress and more generally in clinical ethics that will need to be addressed. If we continue using constraint as a necessary condition of moral distress, there is a risk of neglecting cases of distress arising from morally relevant causes other than constraint. At the least, if we are interested in health care practitioners’ morally relevant experiences of distress, we need to acknowledge there are forms of distress which cannot be linked to constraint but which may be caused by moral challenges such as conflict or uncertainty. We should also be concerned to analyse and to conduct research on these other forms of distress. Yet, generally in the literature on nursing ethics, no name has been suggested for this other form of ‘moral’ distress and no attempts are made to emphasise its importance. If we insisted on defining distress according to constraint (and actually followed this through) there would thus be a large gap in the literature. However, the very fact that there is no attempt to identify other ‘forms’ of moral distress is, I believe, actually related to the failure to adhere to the narrow defini27
M. Lazzarin, A. Biondi, & St. Di Mauro. Moral Distress in Nurses in Oncology and Haematology Units. Nurs Ethics 2012; 19: 183–195. DOI: 10.1177/0969733011416840; J.W. Kayser, D. Nault & G. Ostiguy. Resolving Moral Distress When Caring for Patients Who Smoke While Using Home Oxygen Therapy. Home Healthc Nurse 2012; 30: 208–215. DOI: 10.1097/NHH.0b013e31824c2892. Lazzarin et al. use the term ‘dilemma’, rather than conflict.
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tion and the confusion over what distress is. As discussed in the previous section, the problem is not that researchers simply stick to the narrow definition of moral distress and then neglect other forms of distress. It is rather that they might claim to adopt what seems to be the narrow definition but may not actually follow through with it, and are actually measuring a notion of distress that goes beyond constraint. This is one of the reasons why I endorse a second potential solution: when it comes to defining moral distress, there need be no constraint. This specific cause of distress, while I acknowledge it is of significance, should be decoupled from the definition of moral distress. Why does it seem so important to highlight this specific cause, moral constraint, as part of moral distress? One can see that the notion of constraint is likely to be particularly significant in a clinical setting. It is especially apt in highlighting the conditions in which nurses, who are often low down on the decision-making hierarchy, are likely to work. While moral constraint may be particularly relevant for nurses, it seems clear that other hospital staff, including physicians, could also be vulnerable to the experience of moral constraint, particularly perhaps due to economic and resource constraints that they may feel hampers their treatment of patients.28 Constraint is so significant a concern that many in nursing ethics implicitly accept it as a necessary condition of distress, although some argue it should be expanded to include other forms of constraint not specified by Jameton. Kälvemark et al., for example, claim that Jameton’s definition should be expanded to include legal constraints, while McCarthy and Deady argue that moral distress should be understood as ‘an umbrella concept that captures the range of experiences of individuals who are morally constrained’.29 However, although I can see the importance of investigating moral constraint in a clinical setting, when it comes to defining moral distress and understanding its relationship with moral conflict, we have good reason to be cautious about restricting distress to constraint. One can acknowledge that moral constraint is a particular problem for nurses but without conceding that it should be built into a definition of distress. If there are reasons for building it into the definition then there would be another gap in the literature on nursing ethics: reasons are not provided why moral distress should be seen as a compound phenomenon incorporating the specific ethical cause of constraint. Additionally, there seem to be good reasons why constraint should not be built into the definition of distress. The first of these reasons we have already discussed in the previous section. In cases such as that of Overtreatment 28
Førde & Aasland, op. cit. note 1; Losa Iglesias et al., op. cit. note 1. Kälvemark et al., op. cit. note 1; McCarthy & Deady, op. cit. note 3, p. 254. 29
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where constraint and conflict could occur simultaneously, a definition of moral distress, which makes constraint central to distress, seems to distort the reality of the situation. While constraint may be present and its significance should not be under-estimated, as discussed, the case does not seem to be one which is accurately portrayed as being primarily about constraint: it is not simply that other people are arbitrarily or unfairly standing in the nurse’s way but that they genuinely disagree with the nurse on a moral basis. Furthermore, if we limit distress to cases of constraint we may be dismissing the real-life experiences of many nurses. In practice, nurses and researchers on the topic often refer to certain cases as being examples of moral distress, but moral constraint is not necessarily present and distress may be due to, for example, a lack of knowledge.30 Of course, it is possible that at times the wrong term is being used. For example, one could claim to be experiencing moral distress, while actually experiencing psychological distress with no morally relevant cause.31 However, if we insist on making constraint a necessary condition of moral distress, we will be insisting that one would even be making a mistake in describing as moral distress cases of distress with morally relevant causes, such as moral conflict or moral uncertainty, where these occur without the presence of constraint.
4.2 An expanded definition of moral distress These problems with the narrow definition of distress discussed above indicate that simply insisting that moral distress and conflict should not be considered to be mutually exclusive may not be adequate for clarifying the notion of distress. I would recommend that the narrow definition of distress should no longer be implicitly associated with both the psychological response and the specific ethical cause of moral constraint. Of course, moral distress cannot simply be equivalent to psychological distress either. We need to specify that this form of distress has ‘moral’ causes. Thus I recommend that we substitute the narrow definition with this basis for a definition that allows a broader range of causes: Moral distress is a psychological response to morally challenging situations such as those of moral constraint or moral conflict, or both.32 This definition is only a starting point: it is an adequate response to the particular problems with the narrow definition and the distinction between conflict and distress 30
Hamric, op. cit. note 4. Lützén & Kvist, op. cit. note 3, have found cases of this. 32 I do not claim that this is an entirely new definition of moral distress. This paper is intended as a specific explanation and defence of this definition, in contrast to the influential narrow versions. 31
that I consider in this paper. There may be a need to include further details in this definition, such as examples of what kind of psychological responses, e.g. guilt or anxiety, tend to be experienced as part of moral distress. Using this starting point, the different causes of distress could be used to classify different forms of moral distress. For example, one could refer to moral-constraint distress or moral-conflict distress keeping in mind that some situations could be examples of both of these forms of distress (and that conflict and constraint are not intended to be exhaustive of the possible influences on distress). In this way, if some researchers chose to focus on distress caused by constraint, they could specify this without at the same time indicating, as the narrow definition does, that this is the only form of moral distress. Consider how this definition may be applied to Jameton’s examples of Postoperative Exercise and Overtreatment. If the nurse in each one of these cases does not suffer psychological distress in response to these morally challenging situations then neither case would be one of moral distress. Postoperative Exercise, however, is still likely to be a case of moral conflict and Overtreatment of moral conflict and moral constraint, even if no distress is experienced. If the nurse suffers distress in either of these cases then we can refer to them as cases of moral distress and more specifically as moralconflict distress in the case of Postoperative Exercise and potentially both moral-conflict and moral-constraint distress in the case of Overtreatment.
Acknowledgements I would like to thank Jan-Christoph Heilinger and Verina Wild for valuable comments that have helped me to improve this article. I would also like to thank members of the IDoC project (Assessing the impact of Diagnosis-Related Groups on patient care and professional practice); members of the Institute of Biomedical Ethics, Zurich; and Daniel Strech for their feedback and suggestions. This article was prepared as part of the IDoC project. It does not intend to reflect the views of the project as whole. The project aims to provide empirical data on the impact of DRGs in Switzerland; to provide a critical analysis of the relevant ethical and legal issues; and to develop a set of tools for the long-term evaluation and monitoring of the impact on ethically relevant aspects. It comprises of 5 sub-projects conducted in the disciplines of Medical Ethics (Project Leaders: Nikola Biller-Andorno and Verina Wild, University of Zurich), Law (Project Leaders: Bernice Elger, University of Basel, and Thomas Gächter, University of Zurich), Nursing Sciences (Project Leaders: Rebecca Spirig, University Hospital Zurich), Health Services Research I (Project Leader: Dragana Radovanovic, University of Zurich), and Health Services Research II (Project Leader: Bernard Burnand and John-Paul Vader, University of Lausanne). The IDoC project has been undertaken with financial support from the Swiss National Science Foundation (the SNSF). Carina Fourie is a Post-Doctoral Fellow at the Institute of Biomedical Ethics, University of Zurich. Her research interests include social justice and equality, population level bioethics, and the fairness of health care reform. She has a PhD in Political and Moral Philosophy from University College London.
© 2013 John Wiley & Sons Ltd
