Moral Distress: The Struggle to Uphold Ethics in Healthcare

By: Jennifer Mooney, LMHC

Healthcare professionals have been recognized as heroes and likened to combat soldiers going to battle since the onset of the COVID-19 pandemic. However, even before the pandemic, there was a comparison being made between healthcare professionals and combat veterans. They each have the potential of suffering from "moral distress" and "moral injury".

Moral distress occurs when an individual feels powerless to carry out the ethically appropriate action. In healthcare, this is being unable to provide high-quality care to patients. The best course of action for the patient may be impossible to carry out because it conflicts with what is best for the organization, other providers, other patients, family members, or society as a whole. Moral injury occurs when moral distress is experienced repeatedly and the effects are long-lasting.

It is important to distinguish the difference between an ethical dilemma and moral distress. Ethical dilemmas are an expected part of practicing healthcare. In an ethical dilemma, there are two or more ethically justifiable actions, with no clear solution. Ethical debate can signify that providers are taking steps to ensure quality of care. Moral distress, on the other hand, signifies that providers know the ethical action to take, however feel powerless to do so.

Moral distress can impact many different professionals in the field of healthcare including (but not limited to) nurses, physicians, respiratory therapists, pharmacists, psychologists, social workers, nutritionists, and chaplains. Research has identified a variety of sources of moral distress depending on the sub-specialty within healthcare.

Some common sources of moral distress that have been cited among nurses are:

• Continuing life support even though it is not in the best interest of the patient.
• Inadequate communication about end of life care between providers, patients, and families.
• Inappropriate use of healthcare resources.
• Inadequate staffing or staff inadequately trained to provide the required care.
• Inadequate pain relief provided to patients.
• False hope given to patients and families.

Some common sources of moral distress for physicians include:

• Financial considerations – the practical need for profit and income.
• Electronic health records – distracts from face-to-face care yet valuable for many purposes.
• Risk of litigation – may lead to over-testing, over-analyzing, and over-reacting.

The COVID-19 pandemic has introduced even more sources of moral distress for healthcare professionals. There was a rapid shift from patient-centered ethics to public health ethics. Some scenarios to illustrate moral distress encountered during the pandemic are:

• Staying up-to-date on rapidly shifting protocols is unrealistic.
• Telling families they cannot visit and witnessing patients die alone.
• Treating patients without proper protective gear due to shortages.
• Abandoning bedsides and proper protocols due to high patient volume and low resources.

Signs and symptoms of moral distress include feelings of anger, frustration, hopelessness, isolation, and suicidality. Practitioners also feel belittled, unimportant, or unintelligent. They may contemplate leaving their jobs or leaving their profession altogether.

Several solutions are being proposed for addressing moral distress in the field of healthcare. These involve a collaborative effort between practitioners and organizational leadership. In addition, practitioners across sub-specialties must recognize each other’s moral distress when collaborating care. Some proposed solutions include:

• Speak up – Identify the problem, gather facts, and voice your concern.
• Build support networks – Find colleagues who support acting to address moral distress. Speak with one authoritative voice.
• Focus on change in the work environment – Focus on the work environment rather than individual patients. Similar problems tend to occur over and over.
• Participate in moral distress education – Attend forums and discussions about moral distress to learn all you can.
• Make it interdisciplinary – Multiple views and collaboration are needed to improve a system, especially a complex one, such as a hospital unit.

If you are concerned that you may be experiencing moral distress or moral injury, Behavioral Health Partners are here to help.

{^widget|(widget_displayname)Include+Content|(document)7b5217a1-d3b9-45e0-a6d2-1b48b1b2f53c|(name)IncludeContentWidget|(width)|(height)^}

Members of the Ethical Consult Service has organized a Moral Distress Team to address the ethical repercussions of COVID with staff. Please email the team if interested in a staff discussion.

Epstein, E.G., Delgado, S. (2010). Understanding and addressing moral distress. OJIN: The Online Journal of Issues in Nursing, 15(3).

Hossain, F., Clatty, A. (2020). Self-care strategies in response to nurses’ moral injury during COVID-19 pandemic. Nursing Ethics, advance online publication.

Talbot, S.G., Dean, W. (2018). Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT. (https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/)

Keith Stein | 1/1/2021