June 12, 2015

Moral Distress

I discovered the term Moral Distress in the nursing literature. Hospitals are hot spots for important issues and engage diverse vested interests in daily interactions. Issues of life and death play out, often with conflicts among stakeholders who have different views of what is the right thing to do. Hospitals exist to serve the needs of sick or injured patients. Problems arise when hospitals grow larger, involve increasingly complex technologies, and employ different groups to fulfill the many functions that keep a hospital running. The logistics of managing such a complex institution have routinely overwhelmed patient care. You have armies of people running in all directions, attending meetings, conferences, generating and receiving reports but if you look in patients’ rooms, they are often alone and neglected.

Nurses remain the hospital group most directly involved in patient care. Epstein and Delegado summarized the nurses’ point of view: ”Moral distress occurs when one knows the ethically correct action to take but feels powerless to take that action. Research on moral distress among nurses has identified that the sources of moral distress are many and varied and that the experience of moral distress leads some nurses to leave their jobs, or the profession altogether.“

They and others identified the cognitive dissonance involved generated from several different sources; for example: power imbalances between members of the patient care team, lack of communication among team members, administrative pressure to reduce costs, fear of legal action and hospital policies that conflict with patient needs. Even greater issues arise when medical attitudes and methods are examined and questions are raised about medical prejudices, excessive drug use, inattention to patients, neglect of duty, technical errors and incompetence.

I have no doubt about the distresses nurses’ experience, but the description moral distress is less than accurate. We have understood the humans are critically disputatious and hyper critical of others so that conflict among interacting individuals is common and inevitable. Ethical questions gravitate toward the interfaces between individual freedoms and group discipline. Hospitals are interaction dense, so that anyone working in these institutions will be distressed by the actions of others, at least, some of the time. Coping mechanisms must involve submission to group interests and willingness to compromise, even when I am right and they are wrong. We have also recognized that there is no consensus about the common good, so if you claim superiority by having an ethical position better than others, be prepared for a debate, if not a dangerous fight.

From The Good Person, Morality and Ethics by Stephen Gislason