Moral Distress: A Growing Problem in the Health Professions?

In the insightful and provocative book Final Exam, noted author and liver transplant surgeon Pauline Chen chronicles her medical education and some of the ethical dilemmas physicians face in practice. (1) She describes a hierarchal and often authoritative system of care, reflecting upon the frailties of care providers as well as patients. Though she does not explicitly use the term, Chen implicitly describes the impact of moral distress on health care quality, providers' ability to meet professional and ethical obligations, and subsequent provider satisfaction and retention. Moral distress, as defined by Andrew Jameton in 1984, is the inability of a moral agent to act according to his or her core values and perceived obligations due to internal and external constraints. (2) Others have noted the psychological and physical burdens resulting from moral distress. (3) Today, nurses and their colleagues face ethical issues that seem more complex and more frequent than when Jameton coined the term twenty-five years ago. Although moral distress was originally conceptualized to address ethical issues in nursing, all health care professionals tackle morally relevant questions pertaining to the "rightness" or "wrongness" of decisions, treatments, or procedures, while feeling powerless to change situations they perceive to be morally wrong. Providers frequently say things like, "It's not my job to speak out; no one will listen anyway," or, "This doesn't make any sense; why are we continuing to do this?," or "I want to tell the patient to run." A case drawn from practice shows the anger, guilt, and moral compromise that health care professionals may experience in situations of moral distress. A thirty-five-year-old woman, Ms. Adams (all names and identifying details have been changed), had been diagnosed with acute lymphocytic leukemia that proved resistant to all standard and experimental chemotherapy regimens. She was divorced, uninsured, and had four young children. Previously hospitalized for fungal pneumonia and sepsis that was compounded by a low white blood cell count from experimental treatment, Ms. Adams returned to the emergency room with abdominal pain, nausea, and vomiting. She was readmitted and diagnosed with a pancreatic abscess and small bowel obstruction; she developed intractable pain and pancytopenia--a form of anemia requiring daily transfusions. She was not a candidate for surgery at this time because of her debilitation. Ms. Adams and her family met with the team to discuss her options. She refused hospice care in lieu of continuing aggressive treatments like experimental chemotherapy, believing that she would "be healed and pull through this ordeal." She said that after her blood counts recovered, she wanted to go home to spend time with her children. She chose to remain a "full code" rather than agree to a do-not-resuscitate order. Her parents told the oncology fellow, "She is a fighter and would want to try anything to save her life." Jane, Ms. Adams's primary nurse, struggled to accept these decisions. She had already seen several primary care patients suffer through medically futile chemotherapy. Jane empathized with her patient's desire to keep fighting for her children, but she doubted Ms. Adams would leave the hospital alive. A week later, Ms. Adams again developed sepsis, along with blood in her urine, confusion, rapid breathing, and system failure. Jane asked, "Why are we providing false hope to Ms. Adams and her family? This seems senseless. I feel like I'm inflicting unnecessary suffering on her." The fellow agreed, saying he was also troubled and would not choose this type of treatment for himself or his loved ones. He believed hospice would be the best option for Ms. Adams, but told Jane that his job was to do everything he could to keep her alive, since he must follow his attending physician's orders and the family's wishes. Ms. Adams died two weeks later in the intensive care unit, never making it home to see her children. …