Virtue Ethics in a Value-driven World: Medical Training and Moral Distress

A young child arrived in the pediatric emergency department after an accident resulted in a grievous soft-tissue facial laceration (some details changed to ensure privacy). As the intern rotating on the plastic surgery service, I was called to see the patient, whose laceration involved the forehead down to and through the eyebrow. I called the senior resident who was on home call and sent photos of the injury. Bone was visible in the wound, and I assumed we would need to go to the operating room.

The senior resident advised me to irrigate and close the wound in the emergency department. I disagreed and explained I thought it would be better to treat this patient’s wound in the operating room. The senior resident stood fast, advised me to use local analgesia, and to ask the attending emergency physician to provide sedation. I continued to protest and pointed out that the resulting wound was likely to be unsightly; the senior resident countered that they could always do a scar revision later. My last shot: I explained that the patient’s mother was reluctant to provide personal information, and the emergency department team believed she may be undocumented and was unlikely to bring the child for followup. Unmoved, the senior resident insisted that I treat the wound right there, saying, “You got this.”

As I closed the child’s wound, I knew that what I was doing was just wrong. My younger brother was in a car accident at the age of 4; he had a straightforward laceration, which was closed by a board-certified plastic surgeon in the emergency department. Despite expert care, he retains a lightning-bolt scar on his forehead, which we jokingly refer to as his “Harry Potter scar.” This child's laceration had jagged edges and bone was visible. Would the resident on the phone permit me to close his own child’s laceration? I was certain the resident had asked me to do something unethical, but I nonetheless complied. In retrospect, what I was experiencing is called moral distress.

Moral Distress

Moral distress occurs when an individual feels that external or internal constraints preclude the performance of an ethically appropriate choice or action [3, 7], resulting in painful feelings and psychological imbalance from the current situation being misaligned with our personal values. In short, moral distress is the psychic pain we feel when we know we are about to make an unethical action.

In my case, I believed that the resident was valuing expediency over quality, devaluing the patient in the process. I felt he was willing to make this trade-off because I had conveyed the patient’s lower social status compared with our elective patients. I felt the resident didn’t believe the patient’s value and worth matched that of other patients, whom would merit his coming into the hospital, as he had come in for other less-urgent issues on other patients. I agreed with the technical plan, but I did not think I had the expertise to perform the complicated task at hand because of my limited surgical experience. This felt particularly true because the more-experienced emergency department attending had felt it required a plastic surgeon, which I was not. Further, as an intern on a nonorthopedic service, I did not know who to call further up the hierarchy for help, though I am not sure I would have had done so even if I had known.

The proportion of individuals who report experiencing moral distress is higher among nurses and trainees than among attending physicians [2, 5]. In one New York medical school, 90% of students reported moral distress [8]. The elevated risk of moral distress in nurses and trainees is believed to be caused by the hierarchical nature of medical training. Power gradients can have major influence because they can cause feelings of helplessness. Trainees may feel internally constrained by a lack of knowledge or experience, or they feel externally constrained by institutional structures that prevent ethically appropriate actions [6]. External constraints are more likely to persist, whereas internal constraints, related to knowledge deficits or lack of confidence, tend to decrease with experience.

Impact of Moral Distress

Despite my concerns, I cared for the patient as the resident requested. I followed the patient by checking the medical chart: the child did not followup with the plastic surgery team. I phoned the patient after the missed visit, but I did not hear back. I continued to ask myself—as I do to this day—whether I should have refused to suture the patient and insist the resident come in to perform an expert closure. That the wound looked reasonable at final closure is immaterial—I would not allow an intern to close my daughter’s facial wound, and I should not have done so to this patient.

The experience of moral distress can be cumulative when such situations go unresolved. “The lingering feelings after a morally problematic situation has passed” is a concept known as moral residue [7]. Not coping with this moral residue and moral distress creates predictable patterns such as the numbing of moral sensitivity and withdrawal. Spiritually, this can be seen as a loss of meaning—a feeling of “I don’t know why I am doing this anymore.” Another pattern is the experience of burnout, causing medical practitioners to leave a position or profession.

The Insidious Nature of Moral Distress

How should we recognize and address moral distress in medical practice? There is no easy solution to such a complex problem. Dr. Cynda Rushton and others have focused on our response to moral dilemmas and developing strategies to respond with compassion rather than unregulated moral outrage [12]. Dr. Rushton’s focus on self-regulation is based on neuroscientific research showing that when humans are in a morally distressing situation, they are in an aroused state, appraising their emotions as negative or positive. Well-regulated individuals are better suited to act from a place of principle and compassion, and they are more resilient when faced with morally distressing situations. To return to my particular case, when I called the senior resident, I was in a fight or flight mode, responding with unregulated moral outrage to what I was asked to do. I was motivated by fear and personal distress. I was unable to advocate for my patient or myself. My fear, in part because of my sense of powerlessness, led me to abandon my core values and thereby compromise my integrity.

If this type of moral distress is not well-regulated by our nervous system, it is likely to transition into personal distress. Rather than focusing on the patient, we instead focus on relieving our own personal distress. This was certainly true for me as an intern when I experienced nausea as a physical manifestation of personal distress both the night of the incident and for months after when I thought about it. Dr. Rushton advocates designing strategies to fortify our ability to remain stable in the face of such inevitable situations, moving from a place of victimization to engaged and empowered moral agency [11]. Cultivating this moral resilience does not mean that morally distressing situations will no longer arise. Instead, the goal is to develop an improved foundation for processing these distressing situations, so that these unavoidable situations do not become repetitive traumas leading to personal distress.

How does one move to engaged and empowered moral agency? There is no single answer. I believe that faculty members, such as myself, have a particular responsibility to our trainees. Because of my own experiences, I have deliberately sought opportunities to minimize the external constraints on trainees under my supervision. I tell my residents that I am available—on call or not—to discuss challenging cases or assist in complex situations when they feel constrained in their ability to do the right thing for a patient.

Tools and Techniques for Clinicians

For nontrainees, Dr. Rushton has created a program called The Mindful Ethical Practice and Resilience Academy [10], which teaches ways to recognize the signals of moral distress and to use skills of mindfulness, ethical competence, and moral resilience to respond to them with integrity, by refocusing on the patient. Although her program was developed for nurses, these strategies for developing resilience are universal. One such exercise promoted by J. Bryan Sexton of the Duke University School of Medicine is the “3 good things” framework [9]. He advocates writing down three good things that happened during the day every night before bed. Humans are much more likely to remember negative experiences than positive ones. To quote the psychologist Barbara Fredrickson: “The negative screams at you, but the positive only whispers” [4]. Focusing on the good things helps to increase moral resilience, and early evidence supports the value of this type of technique [9].

As a first step, I encourage healthcare practitioners to recognize situations that provoke moral distress in their own practice and to discuss them with peers or colleagues, acknowledging how these experiences threaten our integrity as providers. The work we do is intense and emotional, and tolerating threats to our professional integrity will lead to burnout and apathy [1]. We must learn to be morally resilient both for ourselves and our patients.