Bioethics Blogs

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.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.