Moral distress in health care: when is it fitting?

Abstract

Nurses and other medical practitioners often experience moral distress: they feel an anguished sense of responsibility for what they take to be their own moral failures, even when those failures were unavoidable. However, in such cases other people do not tend to think it is right to hold them responsible. This is an interesting mismatch of reactions. It might seem that the mismatch should be remedied by assuring the practitioner that they are not responsible, but I argue that this denies something important that the phenomenon of moral distress tells us. In fact, both the practitioners’ tendencies to hold themselves responsible and other people’s reluctance to hold the practitioners responsible get something right. The practitioners may be right that they are responsible in the sense of having failed to meet a binding moral requirement, even when the requirement was impossible to meet. This makes moral distress a fitting response because it correctly represents their own action as a wrongdoing. However, others may meanwhile be right that the practitioners are not responsible in the sense of being culpable and blameworthy. To blame others, or oneself, for certain failures, including those that are unavoidable, would be unfair. My claim depends on distinguishing between the fittingness and the fairness of holding someone (including oneself) responsible for moral failure. Having drawn the distinction, I suggest that moral distress should be addressed in a way that both recognizes it as a fitting response and avoids the unfairness of blame.

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Notes

  1. 1.

    See Tessman (2015, 2017) for my full development and defense of the concept of unavoidable moral failure.

  2. 2.

    See Gilligan (1982, 1987) for the early empirical studies that found a gendered difference in moral development, with women and girls being more likely than men and boys to focus their moral concerns on care rather than on justice; Gilligan’s work has been both developed and challenged by other work in care ethics, including, for instance: Hamington (2004), Held (1995), Held (2006), Kittay (1999, 2019), Noddings (1984, 2002), Ruddick (1989), and Tronto (1994). For work on moral injury in a military context, see: Bica (1999), Boudreau (2011), Litz et al. (2009), Maguen and Litz (2012), Molendijk (2018), Shay (1994, 2002), Sherman (2015), and Wood (2016).

  3. 3.

    This definition is standardly referred to in ethics codes for nurses. For instance, The Canadian Nurses Association’s Code of Ethics for Registered Nurses (2017) states that moral distress: “arises when nurses are unable to act according to their moral judgment (Rodney 2017, s-7). They feel they know the right thing to do, but system structures or personal limitations make it nearly impossible to pursue the right course of action (Jameton 1984; Webster and Baylis 2000; Rodney 2017). Moral distress can lead to negative consequences such as feelings of anger, frustration and guilt, yet it can also be a catalyst for self-reflection, growth and advocacy (Rodney 2017)”.

  4. 4.

    Campbell et al. emphasize that the moral distress “is a matter of having negative emotions or attitudes that are self-directed. These might include self-criticism, guilt, shame, embarrassment, lowered self-esteem, or anger toward oneself or about one’s behavior” (2016, p. 6). They intend their definition to cover cases of “moral uncertainty,” in which a practitioner is unsure of what the morally best course of action is; cases that are just “mildly” troubling, such as when a nurse tolerates or appeases an abusive doctor in order to avoid making the situation worse; cases of moral dilemmas, in which moral requirements conflict in such a way that it is impossible to satisfy both of them, and yet they both remain binding; cases when the distress occurs only retrospectively, when, for example, a physician pursues aggressive treatment under the pressure of an emergency and then later considers whether perhaps that was the wrong thing to do; cases of bad moral luck, such as when a practitioner chooses the foreseeably best treatment, but due to misfortune the treatment results in harm or death; and cases of “distress by association,” when a nurse has some role in the care of a patient whom others are blameworthy for treating in a morally wrong way (2016, pp. 3–6).

  5. 5.

    Technically, this is “reactive” moral distress. Jameton draws a distinction between “initial distress” and “reactive distress.” Initial distress is simply the frustration or anger that a nurse might experience in the moment of decision-making or in facing an obstacle to doing what they take to be the right thing to do. Reactive distress, on which I will focus, is in Jameton’s words “the distress that people feel when they do not act upon their initial distress” (1993, p. 544).

  6. 6.

    The full range of responsibilities that a health care practitioner takes themself to have, or is taken by others to have, include those that might (also) be considered to be professional responsibilities, personal responsibilities, responsibilities to others as members of a moral community, and so on. While each of these may be understood somewhat differently (as well as distinguished from legal responsibilities, which I will not discuss here), I take reactive attitudes to underlie all of them. For instance, self-reactive attitudes may help prompt us to commit to—and maintain a commitment to—professional responsibilities by choosing a profession that comes with these responsibilities.

  7. 7.

    Strawson develops the concept in the context of a discussion of determinism—a context that I will leave to the side. Strawson argues that accepting “the truth of a general thesis of determinism” (1962, p. 195) would have no effect on our practices of responsibility—it would not stop us from having reactive attitudes that express how and in what way other people’s regard for us (and for others) matters to us. It would not lead us to excuse all people from responsibility for their actions (where we tend to excuse when an bad action turns out not to have been based on any underlying ill will), and it would not lead us to exempt all people from counting as responsible agents (as, for instance, we would exempt certain categories of people, such as young children) and thus to see people as “an object of social policy…as a subject for what…might be called treatment…as something…to be managed or handled or cured or trained” (1962, p. 194). Instead, regardless of the truth of determinism, the fact that we are committed to having interpersonal relationships in which other people’s quality of will matters to us means that while it would be logically possible to adopt this “objective attitude” towards others rather than responding to them as a participant in an interpersonal relationship (i.e. responding with the reactive attitudes), it is “practically inconceivable” (1962, p. 197) that we would do so; our valuing of interpersonal relationships precludes it.

  8. 8.

    It is important to note that while Strawson claims that it is natural to react emotionally to other people’s regard for us (or for others) in interpersonal relationships, he is not claiming that certain specific emotions are the natural ones to have. Which particular emotions reflect how someone’s regard matters is determined by many complex factors, (see Ben-Ze’ev 2000) and, of course, is culturally variable (see Flanagan 2017).

  9. 9.

    Our reactive attitudes: “…rest on, and reflect, an expectation of, and demand for, the manifestation of a certain degree of goodwill or regard on the part of other human beings towards ourselves; or at least on the expectation of, and demand for, an absence of the manifestation of active ill will or indifferent disregard” (Strawson 1962, p. 200).

  10. 10.

    Here is what we cannot say to answer the question of when a particular reactive attitude is appropriate: we cannot say that it is appropriate to hold someone responsible when and only when they are really (according to some independent fact) responsible. Instead, the criteria for a reactive attitude’s being appropriate must be internal to the phenomenon. As Strawson puts it: “Inside the general structure or web of human attitudes and feelings…there is endless room for modification, redirection, criticism, and justification. But questions of justification are internal to the structure or relate to modifications internal to it” (1962, p. 208). Of course, someone might be held to what are in one sense “pre-established” responsibilities, such as professional responsibilities; but on another level, we can critically question what our professional responsibilities ought to be, by questioning the values that underlie them.

  11. 11.

    As Austin said of justifications and excuses, when we have a justification for our action, “we accept responsibility but deny that it was bad” and when we have an excuse for our action, “we admit that it was bad but don’t accept full, or even any, responsibility” (1956–1957, p. 2).

  12. 12.

    An exception is Kathryn Norlock, who argues (in an unpublished manuscript entitled “If It’s Excusable, Then Why Do I Feel So Bad?: Accounting for Rational Self-Forgiveness When No One Blames Us”) that there are cases in which taking responsibility for one’s own actions (and even blaming oneself) is appropriate even though it is also appropriate for other people to excuse one’s actions.

  13. 13.

    This recognition of how the concern about fairness functions leads Watson, and other theorists such as Shoemaker (2015), to claim that the accountability or blaming sense of responsibility is not the only sense of responsibility. This allows them to say that holding someone responsible in the sense of blaming them for anything over which they had no control is always inappropriate because it is unfair, but that there are other senses of responsibility that do not involve blaming—for instance, someone can be responsible in the sense that an action is attributable to them—and in these alternative senses a person can be responsible for that which they could not have avoided. For instance, Shoemaker points out that there are “agents who beat themselves up because they view themselves as responsible, full stop… while such agents may be responsible in some sense, they may not be responsible in the way their beating themselves up would license” (2015, p. 120). The path of positing multiple “faces” of responsibility is extremely interesting and offers a way to understand responsibility for a set of wrongdoings that are unavoidable in a very specific way, but in this paper, I do not go down that path (except to explore it briefly in this footnote). Instead, I take a different route to the conclusion that it is in some sense appropriate to hold someone—often oneself—responsible for unavoidable moral failure, despite its being unfair to do so. I do this because the alternatives to the blaming “face” of responsibility that are offered still do not fully illuminate what is going on in most cases of moral distress.

    Watson introduced the idea that there are multiple “faces” of responsibility, suggesting two, namely attributability and accountability, which Shoemaker later expanded to three: attributability, answerability, and accountability. One of the main problems that the distinction between attributability and accountability is meant to addresses is the fact that a moral agent’s lack of control, and the subsequent unavoidability of their actions, does not seem relevant to all kinds of responsibility. The point was originally made in order to respond to concerns about determinism, but the same point seems like it might be able to explain how someone can be responsible for the sorts of unavoidable moral failures that I have been focusing on. In short, the notion of attributability does explain the sense in which one can be responsible for failures that are unavoidable in a very specific way. But ultimately it does not do the work of explaining most cases in which medical practitioners experience moral distress. The attributability sense of responsibility explains why someone may be responsible in the attributability sense despite the fact that they are exempt from blame in the accountability sense; however, most cases of moral distress are cases in which other people accept justifications or excuses (rather than exemptions) to release someone from responsibility in the accountability sense.

    The puzzle that Watson aims to solve is this: there are people who seem like they cannot be rightly blamed for wrong actions, because the action is due to some flaw in their character, a flaw over which they have no control. Given the sort of person that they are—over which they do not have control—it is impossible for them to do the right thing, and perhaps even impossible for them to have the right kind of regard for others. According to Strawson’s original formulation, such people should be exempt from responsibility. It would be wrong to try to hold them responsible; we should take the objective attitude—of managing or treating them—rather than the participant attitudes through which we hold people responsible. To capture the way in which such people may still be said to be responsible, Watson introduces the notion of attributability. When we say that someone is responsible in the sense that some act is attributable to them, we make an aretaic appraisal of them: we can rightly do this whenever an action stems from or discloses someone’s character, or “deep self.” Not all of our actions do stem from or disclose our selves or characters; thus one is not responsible even in the attributability sense if, for instance, one acts on a whim or a compulsion, or by accident, or in ignorance, because such actions do not reveal anything about one’s deep self. But importantly, if—due to no fault of one’s own because one had no control over it—one is a psychopath, or suffered childhood abuse that has shaped one into an angry and violent person, or is a coward and unable to change this fact about oneself, and so on, then one’s actions that stem from these traits are attributable to one: one is responsible for them in this sense.

    This means that in assigning responsibility—in the attributability sense—we may rightly ignore considerations of control. We do not (fully) control who we are, but we are responsible—in the attributability sense—for who we are and for the actions that disclose who we are. Meanwhile, we may be excused from responsibility—in the accountability sense—for the very same actions. For example, someone who is incapable of empathy is responsible in the attributability sense for this shortcoming and for treating people without the kind of concern that depends on empathy, but they are not responsible in the accountability sense for their unavoidable failures to act empathically; we cannot rightly blame them for these failures. Because taking an action to be attributable to someone does not involve blaming them for it or constitute a demand of any kind, no issues about fairness arise.

    Thus attributing an unavoidable failure to act empathically to someone who is incapable of empathy, or a cowardly act to someone who is incapable of courage, can be perfectly appropriate. In doing so, we correctly apprehend their poor quality of will—in this case what Shoemaker calls a poor quality of character, which he takes to be one aspect of will—and respond in a way that seems appropriate, not by blaming them (as we would if we were to hold them accountable) but simply by disesteeming them (Shoemaker 2015). The response seems appropriate because no worries about fairness call its appropriateness into question, and disesteem seems to reflect the rest of what matters to us, such as that people have sufficient empathy, courage, and so on to treat us well. The key insight here is that while fairness considerations block us from holding someone responsible in the accountability sense, accountability is not the only “face” of responsibility, and thus there are other aspects of responsibility for which fairness considerations are not necessarily relevant. Hence the attributability sense of responsibility has been acknowledged to apply to moral failures that are unavoidable, but only in a very particular way: the agent could not avoid being who they are, and who they are is what underlies the action for which they are responsible in the attributability sense.

    We can imagine a situation in which a medical practitioner experiences moral distress over this specific sort of unavoidable failure, but it is not the kind of situation that most typically causes moral distress. Suppose it is out of cowardice that a nurse does not refuse an unethical order, or that a doctor will not take the risk of possible exposure involved in travelling to somewhere with an outbreak of Ebola. Afterwards, they may feel responsible for the consequent suffering that is attributable to them, to their cowardly selves. But more likely, their thoughts would be about how they perhaps could have pushed themselves to overcome their cowardly fears. They would question whether their failure really was unavoidable for them. This is different than taking responsibility for something despite recognizing that it was fully unavoidable.

    Furthermore, if someone’s character or self really does make moral failure unavoidable in predictable ways, this may simply disqualify them for health care jobs. To take an obvious example, people who are incapable of empathy probably should not be nurses. A nurse who was incapable of empathy would be responsible only in the attributability sense for failing to empathize with patients, but still responsible in the accountability sense for becoming a nurse despite knowing they would be unable to perform a nurse’s job.

  14. 14.

    Elsewhere (D’Arms and Jacobson 2000b, p. 732) they call this the “conflation problem”.

  15. 15.

    Because what the object’s evaluative features are depends on our responses to it, what counts as an accurate reflection of evaluative features is determined by some critical process of scrutinizing our own responses, and perhaps endorsing some of them, revising some, and rejecting some. For discussions of what this critical process might be like, see Street’s (2008) characterization of the process through which values, or reasons, are constructed, and see Walker’s (1998, 2003) proposal for making what she calls “transparency testing” part of the process of constructing shared moral understandings; see Tessman (2015) for my critical modifications of both of these positions.

  16. 16.

    Envy, for instance, “involves a complex set of evaluations in presenting its object as enviable. Very roughly, one’s envy portrays a rival as having a desirable possession that one lacks, and it casts this circumstance in a specific negative light” (D’Arms and Jacobson 2000a, p. 66).

  17. 17.

    This version of the moralistic fallacy is evident in Wallace’s main argument in Wallace (1994). His argument proceeds by analyzing the practice of holding people responsible, and he proposes that the account of moral agency that we employ in our practices of holding people responsible can be either accepted or rejected “depending on whether the conditions it describes make it fair” to hold agents, so described, responsible. His conclusion is that we should hold people responsible only when it is fair to do so, and it is fair to do so only when they can avoid wrongdoing, which they can do just in case they have “certain rational powers: the power to grasp and apply moral reasons, and the power to control one’s behavior by the light of such reasons” (1994, p. 7). This is an example of the moralistic fallacy because Wallace assumes that the question of whether or not to have the reactive attitudes through which we hold people responsible reduces entirely to the question of whether or not it is fair to have such reactive attitudes.

  18. 18.

    Other theorists working on the topic of reactive attitudes have developed the notion of quality of will in detail and have considered what qualities of will we demand from others. Shoemaker’s tripartite division of senses of responsibility—attributability, answerability, and accountability—is organized so that each sense of responsibility corresponds to something different that we care about in the quality of other people’s wills (what he calls three “agential features”): our reactive attitudes sometimes fit the quality of someone’s character (corresponding to attributability), sometimes fit the quality of someone’s judgment (corresponding to answerability), and sometimes fit the quality of someone’s regard (corresponding to accountability) (Shoemaker 2015, p. 24). Shoemaker proposes that different reactive attitudes are fitting responses to the three different “objects”: it is fitting to feel admiration/disdain in response to someone’s quality of character, approval/disapproval in response to someone’s quality of judgment, and gratitude/anger in response to someone’s quality of regard (Shoemaker 2015, p. 26). This is a fruitful approach, but I believe that Shoemaker still misses the way in which different relationships and different situations call for different sorts of regard—he seems to think that empathy covers what matters to us in other people’s quality of regard. According to Shoemaker, for an agent to be responsible in the sense of being accountable, or put differently, for an agent to be an appropriate target of the reactive attitude of anger, the agent must be capable of the quality of regard that we seek in our interpersonal relationships, which Shoemaker describes as the complicated form of empathy that is necessary for the agent to avoid slighting others. They must be able to take other people’s normative perspectives into account, either by seeing them as providing reasons—through what Shoemaker calls “evaluational empathy”—or by coming to feel what they feel—through what Shoemaker calls “emotional empathy” (2015, Chap. 3). Fitting anger expresses that we care about other people’s quality of regard understood in this way, and fitting guilt reflects the way we care about our own quality of regard for others.

  19. 19.

    For a different kind of argument supporting the notion that there can be responsibilities that are unfair, but still binding, see Karnein (2014).

  20. 20.

    This is also Frankfurt’s primary context for the concept of the unthinkable. See Frankfurt (2004).

  21. 21.

    It is beyond the scope of this paper to investigate how to ameliorate any of these problems.

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Acknowledgements

An earlier version of this paper was presented at a plenary at the 33rd European Conference on Philosophy of Medicine and Health Care in Oslo, Norway in August 2019. I thank my commentator, Morten Magelssen, as well as members of the audience, for their helpful questions and comments. I would especially like to thank Jan Helge Solbakk and Øivind Michelsen; discussions with them have greatly contributed to my ideas in this paper.

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Tessman, L. Moral distress in health care: when is it fitting?. Med Health Care and Philos 23, 165–177 (2020). https://doi.org/10.1007/s11019-020-09942-7

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Keywords

  • Moral distress
  • Reactive attitudes
  • Moral failure
  • Moral dilemmas
  • Fittingness
  • Moralistic fallacy