Upholding Ethics in Healthcare - Moral Distress Issues

Previously written by Jennifer Mooney LMHC – updated by Marianne Wink, RHIT – retired

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" resulting from tragic events or challenging medical scenarios.

Moral distress occurs when an individual feels powerless to carry out the ethically appropriate action. In healthcare, this is the provider being unable to provide high-quality care to patients. Moral injury occurs when moral distress is experienced repeatedly, and the effects are long-lasting.

It is important to distinguish the difference between ethical dilemmas 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 or singular solution. Ethical debate can ensue and 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 any professional in the field of healthcare. Research has identified a variety of sources of moral distress depending on the type of professional within the healthcare field.

Some examples of moral distress for nurses include:

• Continuing life support even though it does not appear to be in the best interest of the patient.
• Inadequate communication about end-of-life care between providers, patients, and families.
• 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 examples of moral distress for physicians include:

• Financial considerations – the practical need for profit and income.
• Electronic health records – some feel it distracts from face-to-face care. 
• 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 an apparent rapid shift from patient-centered ethics to public health ethics. Some examples of moral distress encountered during the pandemic were:

• Staying up to date on rapidly shifting protocols that appeared to be 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. Providers may contemplate leaving their jobs or leaving their profession altogether due to the discouraging situations.

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. 
• Focus on change in the work environment – Focus on the work environment rather than individual patients.
• Participate in moral distress education – Attend forums and discussions about moral distress.
• Make it interdisciplinary and multidisciplinary – 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. To schedule an intake appointment, give us a call at (585) 276-6900.

Behavioral Health Partners is brought to you by Well-U, offering eligible individuals mental health services for stress, anxiety, and depression. Our team of mental health professionals can accurately assess your symptoms and make recommendations for treatment. 

Resources

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.

7/3/2024