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12/01/2016

Moral Distress in Clinical Ethics: Expanding the Concept

by Alyssa M. Burgart & Katherine E. Kruse

As physician ethicists, we often receive consultations where there is no clear ethical question, but rather, discomfort around value judgments. We have struggled to articulate the meaning of colleagues’ morally uncomfortable experiences. The traditional definition of moral distress is quite restrictive and offers no vocabulary for our observations. Clinicians know something is wrong and that it might be of a moral nature. However, they don’t know the “right” thing to do, and the institution isn’t preventing them from acting. In our practice, most ethics consults do not have “right” answers, but they almost universally have people struggling with moral unease. The currently available vocabulary does not leave room for this milieu. For lack of better terms, we have referred to these as “moral distress-lite”: not quite destructive to moral integrity and not intractable in the situation, but unsettling enough that they deserve thoughtful attention, exploration and, when possible, mediation and resolution.

It is concerning that the traditional definition of moral distress implies that one’s moral integrity must be in extremis in order to deserve protection. Perhaps these other forms of moral distress are analogous to a patient progressing to cardiac arrest; frequently there is a constellation of smaller risk factors and injuries that accumulate over time leading to an ultimate catastrophe. Like such a patient, each of these smaller injuries might be warning signs that could be acted on to mitigate the situation and prevent a negative outcome. This expanded understanding of moral distress adds value to recognizing the moral microclimate of institutions, rather than requiring a moral unraveling or disaster to be underway before paying it any mind. If we do not validate the importance of “more minor” or “less momentous” cases of moral distress, there is great potential that there will be a cumulative effect over time into a situation that may fester, ultimately becoming catastrophic.

This issue’s target article by Campbell, Ulrich, and Grady gives us permission to place “moral distress-lite” experiences under the umbrella definition of “moral distress.” They scoop up lingering, sometimes subtle elements of moral distress and give them credence. We see tremendous value in granting a name to what we observe through ethics consultation. Through illustrative cases, the authors demonstrate that it is possible to validate other less severe distresses as equally important components of a hospital’s moral environment.

Given its powerful emotional context, traditional moral distress has been low hanging fruit for academic exploration. Today, this important concept is universally accepted as a problem, making room for exploration of the lesser known, more nuanced relatives of moral distress: mild distress, moral uncertainty, delayed distress, and moral bad luck.

In the accompanying commentaries, you will hear from authors who believe this proposed change in definition is too broad and will only serve to dilute the growing body of moral distress work. Others agree with the proposed definition and champion the change. Yet, others provide an interesting analysis of the flavors of moral distress.

While there are interesting arguments in this issue to the contrary, we find that Campbell’s expansion is worth the risks. The ability to name our lived experience is fundamentally important when speaking with other ethicists and clinicians. It seems natural, that as our understanding of disease evolves, so does our understanding of moral distress.

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