Moral distress is a well-documented phenomenon in the nursing profession, and increasingly thought to be implicated in a nation-wide nursing shortage in the US. First identified by the philosopher Andrew Jameton in 1984, moral distress has also proven resistant to various attempts to prevent its occurrence or at least mitigate its effects. While this would seem to be bad news for nurses and their patients, it is potentially good news for philosophical counselors, for whom there is both socially important and (...) philosophically interesting work to be done. In an effort to encourage such work, this paper explicates the philosophical (as opposed to more purely psychological or institutional) contours of the problem. A subsequent paper, titled 'A Philosophical Counseling Approach to Moral Distress,' will highlight ways in which such a response would differ from the strategies so far deployed within the nursing profession. (shrink)

Stresses on healthcare systems and moral distress among clinicians are urgent, intertwined bioethical problems in contemporary healthcare. Yet conceptualizations of moral distress in bioethical inquiry often overlook a range of routine threats to professional integrity in healthcare work. Using examples from our research on frontline physicians working during the COVID-19 pandemic, this article clarifies conceptual distinctions between moral distress, moral injury, and moral stress and illustrates how these concepts operate together in healthcare work. Drawing from the philosophy of healthcare, we (...) explain how moral stress results from the normal operations of overstressed systems; unlike moral distress and moral injury, it may not involve a sense of powerlessness concerning patient care. The analysis of moral stress directs attention beyond the individual, to stress-generating systemic factors. We conclude by reflecting on how and why this conceptual clarity matters for improving clinicians’ professional wellbeing, and offer preliminary pathways for intervention. (shrink)

This paper develops a philosophical account of moral disruption. According to Robert Baker, moral disruption is a process in which technological innovations undermine established moral norms without clearly leading to a new set of norms. Here I analyze this process in terms of moral uncertainty, formulating a philosophical account with two variants. On the harm account, such uncertainty is always harmful because it blocks our knowledge of our own and others’ moral obligations. On the qualified harm account, there is no (...) harm in cases where moral uncertainty is related to innovation that is “for the best” in historical perspective or where uncertainty is the expression of a deliberative virtue. The two accounts are compared by applying them to Baker’s historical case of the introduction of mechanical ventilation and organ transplantation technologies, as well as the present-day case of mass data practices in the health domain. (shrink)

The concept of moral distress comes from nursing ethics, and was initially defined as ‘…when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’. There is a large body of literature associated with moral distress, yet multiple definitions now exist, significantly limiting its usefulness. We undertook a systematic review of the argument-based bioethics literature on this topic as the basis for a critical appraisal, identifying 55 papers for analysis. (...) We found that moral distress is most frequently framed around individual experiences of distress in relation to local practices and constraints, and understood in terms of power relations and workplace hierarchies. This understanding is directly derived from, and often still seen as specific to, nursing. Frequently the perspective of the morally distressed individual is privileged. Understandings of moral distress have evolved towards an ‘occupational health approach’, with the assumption that moral distress should be measured and prevented. Counter-perspectives were identified, highlighting conceptual problems. Based on our review, we propose a redefinition of moral distress: ‘Ethical unease or disquiet resulting from a situation where a clinician believes they have contributed to avoidable patient or community harm through their involvement in an action, inaction or decision that conflicts with their own values’. This definition is specific enough for research use, anchored in clinicians’ professional responsibilities and concerns about harms to patients, framed relationally rather than hierarchically, and amenable to multiple perspectives on any given morally distressing situation. (shrink)

Austerity, by its very nature, imposes constraints by limiting the options for action available to us because certain courses of action are too costly or insufficiently cost effective. In the context of healthcare, the constraints imposed by austerity come in various forms; ranging from the availability of certain treatments being reduced or withdrawn completely, to reductions in staffing that mean healthcare professionals must ration the time they make available to each patient. As austerity has taken hold, across the United Kingdom (...) and Europe, it is important to consider the wider effects of the constraints that it imposes in healthcare. Within this paper, we focus specifically on one theorised effect—moral distress. We differentiate between avoidable and unavoidable ethical challenges within healthcare and argue that austerity creates additional avoidable ethical problems that exacerbate clinicians’ moral distress. We suggest that moral resilience is a suitable response to clinician moral distress caused by unavoidable ethical challenges but additional responses are required to address those that are created due to austerity. We encourage clinicians to engage in critical resilience and activism to address problems created by austerity and we highlight the responsibility of institutions to support healthcare professionals in such challenging times. (shrink)