Moral distress is a phenomenon that has been receiving increasing attention in nursing and other health care disciplines. Moral distress is a concept that entered the nursing literature – and subsequently the health care ethics lexicon – in 1984 as a result of the work done by American philosopher and bioethicist Andrew Jameton. Over the past decade, research into moral distress has extended beyond the profession of nursing as other health care disciplines have come to question the impact of moral (...) constraint on individual practitioners, professional practice, and patient outcomes. Along with increased interest in the phenomenon of moral distress have come increasing critiques – critiques that in their essence point to a serious lack of conceptual clarity in the definition, study, and application of the concept. Foundational to gaining conceptual clarity in moral distress in order to develop strategies to prevent and ameliorate the experience is a careful revisiting of the epistemological assumptions underpinning our knowledge and use of the concept of moral distress. It is our contention that the conceptual challenges reveal flaws in the original understanding of moral distress that are based on an epistemological stance that holds a linear conception of cause and effect coupled with a simplistic perspective of ‘constraint’ and ‘agency’. We need a more nuanced approach to our study of moral distress such that our ontological and epistemological stances help us to better appreciate the complexity of moral agents acting in organizational contexts. We believe that critical realism offers such a nuanced approach. (shrink)

We report the results of an investigation of nurses’ and physicians’ sensitivity to ethical dimensions of clinical practice. The sample consisted of 113 physicians working in general medical settings, 665 psychiatrists, 150 nurses working in general medical settings, and 145 nurses working in psychiatry. The instrument used was the Moral Sensitivity Questionnaire (MSQ), a self-reporting Likert-type questionnaire consisting of 30 assumptions related to moral sensitivity in health care practice. Each of these assumptions was categorized into a theoretical dimension of moral (...) sensitivity: relational orientation, structuring moral meaning, expressing benevolence, modifying autonomy, experiencing moral conflict, and following the rules. Significant differences in responses were found between health care professionals from general medical settings and those working in psychiatry. The former agreed to a greater extent with the assumptions in the categories ‘meaning’ and ‘autonomy’ and to a lesser degree with the categories ‘benevolence’ and ‘conflict’. Moreover, those from the psychiatric sector agreed to a greater extent to the use of coercion if necessary. Significant differences were also found for some of the MSQ categories, between physicians and nurses, and between males and females. (shrink)

Much research is currently being conducted on health care practitioners' experiences of moral distress, especially the experience of nurses. What moral distress is, however, is not always clearly delineated and there is some debate as to how it should be defined. This article aims to help to clarify moral distress. My methodology consists primarily of a conceptual analysis, with especial focus on Andrew Jameton's influential description of moral distress. I will identify and aim to resolve two sources of confusion about (...) moral distress: the compound nature of a narrow definition of distress which stipulates a particular cause, i.e. moral constraint, and the distinction drawn between moral dilemma and moral distress, which implies that the two are mutually exclusive. In light of these concerns, I argue that the definition of moral distress should be revised so that moral constraint should not be a necessary condition of moral distress, and that moral conflict should be included as a potential cause of distress. Ultimately, I claim that moral distress should be understood as a specific psychological response to morally challenging situations such as those of moral constraint or moral conflict, or both. (shrink)

Moral distress has received much attention in the international nursing literature in recent years. In this article, we describe the evolution of the concept of moral distress among nursing theorists from its initial delineation by the philosopher Jameton to its subsequent deployment as an umbrella concept describing the impact of moral constraints on health professionals and the patients for whom they care. The article raises worries about the way in which the concept of moral distress has been portrayed in some (...) nursing research and expresses concern about the fact that research, so far, has been largely confined to determining the prevalence of experiences of moral distress among nurses. We conclude by proposing a reconsideration, possible reconstruction and multidisciplinary approach to understanding the experiences of all health professionals who have to make difficult moral judgements and decisions in complex situations. (shrink)

As professionals, nurses are engaged in a moral endeavour, and thus confront many challenges in making the right decision and taking the right action. When nurses cannot do what they think is right, they experience moral distress that leaves a moral residue. This article proposes a theory of moral distress and a research agenda to develop a better understanding of moral distress, how to prevent it, and, when it cannot be prevented, how to manage it.

Our lives are such that moral wrongdoing is sometimes inescapable for us. We have moral responsibilities to persons which may conflict and which it is wrong to violate even when they do conflict. Christopher W. Gowans argues that we must accept this conclusion if we are to make sense of our moral experience and the way in which persons are valuable to us. In defending this position, he critically examines the recent moral dilemmas debate. He maintains that what is important (...) in this debate is not whether there are irresolvable moral conflicts, but whether there are moral conflicts in which wrongdoing is unavoidable. Though it would be incoherent to conclude moral deliberation by deciding to perform incompatible actions, he argues that there is nothing incoherent in supposing that we have conflicting moral responsibilities. In this way, he shows that it is possible to capture the intuitions of those who have defended the idea of moral dilemmas while meeting the objections of those who have rejected this idea. Gowans carefully evaluates utilitarian and Kantian analyses of moral dilemmas. He argues that these approaches eliminate genuine moral conflict only by displacing persons as direct objects of moral concern. As an alternative, he develops a more concrete account in which moral responsibilities to persons are central. The book also includes discussions of Melville's Billy Budd, methodology in moral philosophy, moral pluralism, moral tragedy, and "dirty hands" in politics. (shrink)

Plural and conflicting values are often held to be conceptually problematic, threatening the very possibility of ethics, or at least rational ethics. Rejecting this view, Stocker first demonstrates why it is so important to understand the issues raised by plural and conflicting values, focusing on Aristotle's treatment of them. He then shows that plurality and conflict are commonplace and generally unproblematic features of our everyday choice and action, and that they do allow for a sound and rational ethics.

A strong tradition in philosophy denies the possibility of moral dilemmas. Recently, several philosophers reversed this tradition. In this dissertation, I clarify some fundamental issues in this debate, argue for the possibility of moral dilemmas, and determine some implications of this possibility. ;In chapter I, I define moral dilemmas roughly as situations where an agent morally ought to adopt each of two alternatives but cannot adopt both. Moral dilemmas are resolvable if and only if one of the moral oughts overrides (...) the other. ;In chapter II, I criticize several opponents of moral dilemmas, including utilitarians, Kant, Aquinas, and Ross. My main criticism is that no opponent of moral dilemmas can adequately justify moral residue . ;Chapters III and IV concern the two main arguments against the possibility of moral dilemmas. First, the argument for 'ought' implies 'can' runs as follows. If the agent cannot adopt both, then it is not the case that the agent ought to adopt both. But the agent ought to adopt both, since the agent ought to adopt each . Thus, the defining judgements of a moral dilemma seem to imply a contradiction. In response, I argue that the relation between 'ought' and 'can' is not a logical implication but a conversational implicature. ;Chapter IV concerns the argument from 'ought' implies 'permitted': If the agent ought to adopt one alternative, then the agent is permitted to adopt that alternative, which means that it is not the case that the agent ought not to adopt that alternative. But the agent ought not to adopt that alternative, since the agent ought to adopt the other alternative and cannot adopt both. I respond that 'ought' does not logically imply but conversationally implicates 'permitted'. ;In chapter V, I argue that, despite recent claims, both moral realism and anti-realism are compatible with the possibility of moral dilemmas. Thus, there are several reasons to accept and no reasons to deny the possibility of moral dilemmas. (shrink)

In one of the most frequently quoted passages in the history of emotion research, William James (1884: 189f) announces that emotions occur when the perception of an exciting fact causes a collection of bodily changes, and “our feeling of the same changes as they occur IS the emotion.” The same idea occurred to Carl Lange (1984) around the same time. These authors were not the first to draw a link between the emotions and the body. Indeed, this had been a (...) central theme of Descartes’ exquisite opus, The Passions of the Soul. But James and Lange wanted to push things farther than most, suggesting that emotions are exhausted by bodily changes or perceptions thereof. Other kinds of mental episodes might co-occur when we have an emotion state. For James, an emotion follows an exciting perception. But the exciting perception is not a part of the emotion it excited (Ellsworth, 1994, reads James differently, but see Reisenzein et al.’s 1995 convincing response). The majority of contemporary emotion researchers, especially those in philosophy, find this suggestion completely untenable. Surely, emotions involve something more. At their core, emotions are more like judgments or thoughts, than perceptions. They evaluate, assess, or appraise. Emotions are amendable to rational assessment; they report, correctly or incorrectly, on how we are faring in the world. Within this general consensus, there is a further debate about whether the body should figure into a theory of emotions at all. Perhaps James and Lange offer a theory that is not merely incomplete, but entirely off base. Where they view judgments as contingent and non-constitutive concomitants of emotions, it is actually bodily perceptions that deserve this demotion. Perhaps emotions can be, and often are, disembodied in some fundamental sense. (shrink)

Originally published in 1992 this book attacks many recent philosophical and psychological theories of the emotions and argues that our emotions themselves have intrinsic moral significance. He demonstrates that a proper understanding of the emotions reveals the fundamental role they play in our moral lives and the practical consequences that arise from being morally responsible for our emotions.

A scholarly edition of a work by David Hume. The edition presents an authoritative text, together with an introduction, commentary notes, and scholarly apparatus.

The moral distress of psychologists working in psychiatric and mental health care settings was explored in an interdisciplinary, hermeneutic phenomenological study situated at the University of Alberta, Canada. Moral distress is the state experienced when moral choices and actions are thwarted by constraints. Psychologists described specific incidents in which they felt their integrity had been compromised by such factors as institutional and interinstitutional demands, team conflicts, and interdisciplinary disputes. They described dealing with the resulting moral distress by such means as (...) silence, taking a stance, acting secretively, sustaining themselves through work with clients, seeking support from colleagues, and exiting. Recognizing moral distress can lead to a significant shift in the way we perceive moral choices and understand the moral context of practice. (shrink)

In this article we distinguish between philosophical bioethics (PB), descriptive policy orientated bioethics (DPOB) and normative policy oriented bioethics (NPOB). We argue that finding an appropriate methodology for combining empirical data and moral theory depends on what the aims of the research endeavour are, and that, for the most part, this combination is only required for NPOB. After briefly discussing the debate around the is/ought problem, and suggesting that both sides of this debate are misunderstanding one another (i.e. one side (...) treats it as a conceptual problem, whilst the other treats it as an empirical claim), we outline and defend a methodological approach to NPOB based on work we have carried out on a project exploring the normative foundations of paternal rights and responsibilities. We suggest that given the prominent role already played by moral intuition in moral theory, one appropriate way to integrate empirical data and philosophical bioethics is to utilize empirically gathered lay intuition as the foundation for ethical reasoning in NPOB. The method we propose involves a modification of a long-established tradition on non-intervention in qualitative data gathering, combined with a form of reflective equilibrium where the demands of theory and data are given equal weight and a pragmatic compromise reached. (shrink)

A perfectly matched layer (PML) absorbing material composed of a uniaxial anisotropic material is presented for the truncation of finite-difference time-domain (FDTD) lattices. It is shown that the uniaxial PML material formulation is mathematically equivalent to the perfectly matched layer method published by Berenger (see J. Computat. Phys., Oct. 1994). However, unlike Berenger's technique, the uniaxial PML absorbing medium presented in this paper is based on a Maxwellian formulation. Numerical examples demonstrate that the FDTD implementation of the uniaxial PML medium (...) is stable, equal in effectiveness as compared to Berenger's PML medium, while being more computationally efficient. (shrink)

Introduction In recent years there has been a welcome reawakening of philosophical interest in the emotions. A significant number of contemporary ...

In this paper I consider the routine moral burden of occupying a professional role and having to negotiate tensions between the normative expectations attached to that role and one's own personal moral compass. Using an example to introduce this central issue I then seek to explore it through a discussion of the tensions between, and spaces between, ‘identifying’ with one's role and ‘separating’ oneself from one's role. I suggest that ethical integrity at work is revealed through the successful negotiation of (...) these tensions, but that such negotiation depends upon the power and other resources available to individual professionals. Finally I argue that this discussion of ‘the ethics of role occupation’ has important implication for ‘the ethics of role construction’ and adds weight to concerns about the potential moral costs of managerialism. (shrink)

H.L.A. Hart’s lost and found essay ‘Discretion’ has provided new insight into the issue of how legal systems can cope with indeterminacy in the law. The so-called ‘open texture’ of law calls for the exercise of judicial discretion, which, I argue, renders judges susceptible to the problem of dirty hands. To show this, I frame the problem as being open to an array of appropriate emotional responses, namely, various senses of guilt. With these responses in mind, I revise an example (...) from Michael Walzer’s original analysis in a way that highlights purely personal sacrifices in solutions to dirty hands situations. I then turn to an account of moral emotions in legal decision-making and show how judges—in failing to advance all interests—might be left with a unique sense of guilt. With an application of this account to Hart’s legal positivism, it can be seen that a judge’s hands are often dirtied in resolving borderline cases. If discretion leaves judges in situations where they must do wrong in order to do right, Hart’s endorsement of a closure view of wrongdoing will lead to difficulties in how he can explain the presence of moral remainders in jurisprudence. (shrink)

In a moving examination of one of the most troubling issues of our time, Lonny Shavelson puts a human face on the legal and ethical discussions that surround assisted suicide. By recounting with great intimacy and compassion the personal histories of five terminally ill people, he exposes the depth and complexity of this explosive issue.

Aims:The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress.Background:Moral distress is said to occur when one has made a moral judgement but is unable to act upon it. However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature. As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenon.Design:Systematic literature review and narrative synthesis (November (...) 2015–March 2016).Data sources:Ovid MEDLINE®In-Process & Other Non-Indexed Citations 1946–Present, PsycINFO®1967–Present, CINAHL®Plus 1937–Present, EMBASE 1974–24 February 2016, British Nursing Index 1994–Present, Social Care Online, Social Policy and Practice Database (1890–Present), ERIC (EBSCO) 1966–Present and Education Abstracts.Review methods:Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis.Results:In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity.Conclusion:We suggest the combination of (1) the experience of a moral event, (2) the experience of ‘psychological distress’ and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress. (shrink)

In recent years there has been a wealth of literature arguing the need for empirical and interdisciplinary approaches to bioethics, based on the premise that an empirically informed ethical analysis is more grounded, contextually sensitive and therefore more relevant to clinical practice than an ‘abstract’ philosophical analysis. Bioethics has (arguably) always been an interdisciplinary field, and the rise of ‘empirical’ (bio)ethics need not be seen as an attempt to give a new name to the longstanding practice of interdisciplinary collaboration, but (...) can perhaps best be understood as a substantive attempt to engage with the nature of that interdisciplinarity and to articulate the relationship between the many different disciplines (some of them empirical) that contribute to the field. It can also be described as an endeavour to explain how different disciplinary approaches can be integrated to effectively answer normative questions in bioethics, and fundamental to that endeavour is the need to think about how a robust methodology can be articulated that successfully marries apparently divergent epistemological and metaethical perspectives with method. This paper proposes ‘Reflexive Bioethics’ (RB) as a methodology for interdisciplinary and empirical bioethics, which utilizes a method of ‘Reflexive Balancing’ (RBL). RBL has been developed in response to criticisms of various forms of reflective equilibrium, and is built upon a pragmatic characterization of Bioethics and a ‘quasi-moral foundationalism’, which allows RBL to avoid some of the difficulties associated with RE and yet retain the flexible egalitarianism that makes it intuitively appealing to many. (shrink)

The plethora of literature on moral distress has substantiated and refined the concept, provided data about clinicians’ (especially nurses’) experiences, and offered advice for coping. Fewer scholars have explored what makes moral distress _moral_. If we acknowledge that patient care can be distressing in the best of ethical circumstances, then differentiating distress and moral distress may refine the array of actions that are likely to ameliorate it. This article builds upon scholarship exploring the normative and conceptual dimensions of moral distress (...) and introduces a new tool to map moral distress from emotional source to corrective actions. The Moral Distress Map has proven useful in clinical teaching and ethics-related debriefings. (shrink)

This article suggests that there is a relationship between successfully maintaining integrity in nursing and the practical provision of opportunities for shared reflection offered by good clinical supervision. In order to establish this case, I will first give some definitions and then proceed to consider how these ideas relate conceptually. The article makes no attempt to offer empirical research as confirmation, but provides a conceptual and moral argument making use of anecdotes for puposes of clarification and illumination. It is the (...) author’s belief that, if it is understood and implemented properly, clinical supervision offers a radical challenge to nursing’s existing culture. If nurses are interested in the survival of the profession, it is perhaps a challenge that has to be addressed. (shrink)

This article discusses the challenging context that health care professionals are confronted with, and the impact of this context on their emotional experiences. Care ethics considers emotions as a valuable source of knowledge for good care. Thinking with care ethical theory and looking through a care ethical lens at a practical case example, the authors discern reflective questions that shed light on a care ethical approach toward the role of emotions in care practices, and may be used by practitioners and (...) facilitators for care ethical reflection on similar cases, in the particular and concrete context where issues around emotional experiences arise. The authors emphasize the importance of allowing emotions to exist, to acknowledge them and to not repress them, so that they can serve as a vehicle for ethical behavior in care practices. They stress the difference between acknowledging emotions and expressing them limitlessly. Formational practices and transformational research practices are being proposed to create moral space in care institutions and to support health care professionals to approach the emotionally turbulent practices they encounter in a way that contributes to good care for all those involved. (shrink)

Experiences of moral distress encountered in psychiatric practice were explored in a hermeneutic phenomenological study. Moral distress is the state experienced when moral choices and actions are thwarted by constraints. Psychiatrists describe struggling ‘to do the right thing’ for individual patients within a societal system that places unrealistic demands on psychiatric expertise. Certainty on the part of the psychiatrist is an expectation when judgments of dangerousness and/or the need for coercive treatments are made. This assumption, however, ignores the uncertainty and (...) complexity of reality. Society entrusts psychiatrists to care for and treat those among its most vulnerable members: persons deemed to have a severely diminished capacity for autonomy due to a mental disorder. Simultaneously, psychiatrists are held accountable by society for the protection of the public. Moral distress arose for psychiatrists in their efforts to fulfill both roles. They described an ‘outsider/insider’ status and the ways in which they attempted to cope with moral distress. (shrink)