The Journal of Clinical Ethics, 28, number 1, Spring 2017
At the Bedside
Fourteen Important Concepts Regarding Moral Distress
Edmund G. Howe
I suggest that we may want to strive, over time, to change our present professional-cultural view, from one that sees an expression of moral distress as a threat, to a professional-cultural view that welcomes these challenges. Such an effort to better medicine would not only include dissenting clinicians, but patients (and their loved ones) as well.
Special Section on Moral Distress
Harnessing the Promise of Moral Distress: A Call for Re-Orientation
Alisa Carse and Cynda Hylton Rushton
Despite over three decades of research into the sources and costs of what has become an “epidemic” of moral distress among healthcare professionals, spanning many clinical disciplines and roles, there has been little significant progress in effectively addressing moral distress. We believe the persistent sense of frustration, helplessness, and despair still dominating the clinical moral distress narrative signals a need for re-orientation in the way moral distress is understood and worked with. Most fundamentally, moral distress reveals moral investment and energy. It is the troubled call of conscience, an expression of fidelity to moral commitments seen as imperiled or compromised.
It is crucial that we find ways to empower clinicians in heeding this call—to support clinicians’ moral agency and voice, foster their moral resilience, and facilitate their ability to contribute to needed reform within the organizations and systems in which they work. These objectives must inform creative expansion in the design of strategies for addressing moral distress in the day-to-day of clinical practice. We include suggestions about promising directions such strategies might take in the hope of spurring further innovation within clinical environments.
Focus More on Causes and Less on Symptoms of Moral Distress
Tessy A. Thomas and Laurence B. McCullough
In this commentary on Carse and Rushton’s call for reorientation of moral distress, we state agreement with the authors that the discourse of moral distress should refocus on the moral components of integrity. We then explain how our philosophical taxonomy of moral distress, mentioned by the authors, appeals to moral integrity. In this process, we clarify our taxonomy’s appeal to Aristotle’s concept of akrasia. We conclude by offering support of Carse and Rushton’s challenge to organizations to strengthen moral integrity by fostering resilience.
Using Moral Distress for Organizational Improvement
James E. Sabin
Moral distress is a major problem for nurses, other clinicians, and the health system itself. But if properly understood and responded to, it is also a promising guide for healthcare improvement. When individuals experience moral distress or burnout, their reports must be seen as crucial data requiring careful attention to the individuals and to the organization. Distress and burnout will often point to important opportunities for system improvements, which may in turn reduce the experience of distress. For this potential virtuous cycle to happen, individuals must be able to articulate their concerns without fear of retribution, and organizational leaders must be able to listen in an undefensive, improvement-oriented manner.
Looking at the Positive Side of Moral Distress: Why It’s a Problem
Elizabeth G. Epstein and Ashley R. Hurst
Moral distress, is, at its core, an organizational problem. It is experienced on a personal level, but its causes originate within the system itself. In this commentary, we argue that moral distress is not inherently good, that effective interventions must address the external sources of moral distress, and that while there is a place for resilience in the healthcare professions, it cannot be an effective antidote to moral distress.
Moral Distress: Conscious and Unconscious Feelings
William J. Winslade
In analyzing moral distress, perhaps greater attention should be given to the possible implicit sources of feelings of distress, as well as explicit sources.
When Not to Rescue: An Ethical Analysis of Best Practices for Cardiopulmonary Resuscitation and Emergency Cardiac Care
Nancy S. Jecker and Arthur R. Derse
It is now a default obligation to provide cardiopulmonary resuscitation (CPR), in the absence of knowledge of a patient’s or surrogate’s wishes to the contrary. We submit that it is time to re-evaluate this position. Attempting CPR should be subject to the same scrutiny demanded of other medical interventions that involve balancing a great benefit against grievous harms.
A Framework for Ethical Decision Making in the Rehabilitation of Patients with Anosognosia
Anna Rita Egbert
Currently, the number of patients diagnosed with impaired self-awareness of their own deficits after brain injury—anosognosia—is increasing. One reason is a growing understanding of this multifaceted phenomenon. Another is the development and accessibility of alternative measurements that allow more detailed diagnoses. Anosognosia can adversely affect successful rehabilitation, as often patients lack confidence in the need for treatment. Planning such treatment can become a complex process full of ethical dilemmas.
To date, there is no systematic way to deal with different aspects of anosognosia rehabilitation planning. This is the first article to present a framework for ethical decision making in establishing rehabilitation plans that are focused on increasing patients’ self-awareness of their own deficits after brain injury. It concentrates especially on addressing the ethical dilemmas that may arise, and describes stepwise procedures that can be applied to distinct theoretical approaches, as well as diagnostic and rehabilitation methods. To show the flexibility of the use of this framework, alternative approaches are discussed.
Case and Analysis
Family Loyalty as a Cultural Obstacle to Good Care: The Case of Mrs. Indira
What is the responsibility of the physician when a capacitated patient assigns decision-making authority to a surrogate who does not act in the patient’s best interest?
Complexities in Caregiving: Comforts, Cultures, Countries, Conversations, and Contracts
Shenbagam Dewar and Rajan Dewar
As depicted in the case of Mrs. Indira, decision making by patients and surrogates may be complicated by multiple factors, including care, comfort, country, and culture.
Legal Briefing: New Penalties for Ignoring Advance Directives and Do-Not-Resuscitate Orders
Thaddeus Mason Pope
Patients in the United States have been subject to an ever-growing “avalanche” of unwanted medical treatment. This is economically, ethically, and legally wrong. As one advocacy campaign puts it: “Patients should receive the medical treatments they want. Nothing less. Nothing more.” First, unwanted medical treatment constitutes waste (and often fraud or abuse) of scarce healthcare resources. Second, it is a serious violation of patients’ autonomy and self-determination. Third, but for a few rare exceptions, administering unwanted medical treatment contravenes settled legal rules and principles. This “Legal Briefing” describes a central and growing role for the law. Specifically, courts and agencies have increasingly imposed penalties on healthcare providers who deliberately or negligently disregard advance directives and DNR (do-not-resuscitate) orders. I group these legal developments into the following five categories:
1. Five Types of Unwanted Medical Treatment
2. State and Federal Duties to Follow Advance Directives
3. Doctors Hospital of Augusta v. Alicea
4. Other Lawsuits for Ignoring Advance Directives
5. Administrative Penalties for Ignoring Advance Directives.