Definitions of Moral Distress

In the 16 documents, it was found that moral distress, moral stress, and ethical distress are expressions used in a concomitant way, describing similar phenomena. Two of the documents used “moral stress” as an overall expression, ^{Reference Nilsson, Sjöberg, Kallenberg and Larsson25,Reference Noutsou26} one document used “ethical distress,” while others drew a distinction between moral stress and moral distress. ^{Reference Durocher, Chung, Rochon, Henrys, Olivier and Hunt27} “Complex humanitarian distress” was also mentioned, describing ethical distress among humanitarian workers. ^{Reference Nordahl28}

A majority of the definitions and phrasing of moral distress refered to Andrew Jameton’s definition: “Moral distress arises when one knows the right thing to do, but institutional constrains make it nearly impossible to pursue the right course of action.” ^{Reference Jameton12,Reference Jameton13} Raines later expanded on Jameton’s definition of moral distress: “(Moral distress) occurs when one knows the right thing to do, but institutional or other constraints make it difficult to pursue the right course of action.” ^{Reference Raines29} This definition was referred to in one document, ^{Reference Noutsou26} while four other documents ^{Reference Nilsson, Sjöberg, Kallenberg and Larsson25,Reference Gotowiec and Cantor-Graae30–Reference Smith, Ahmed and Smith32} referred to a combination of definitions. These combinations referred to Jameton’s definition, and later broader definitions, such as this definition by Kälvemark, Höglund, and Hansson: “Traditional negative stress symptoms that occur due to situations that involve an ethical dimension and where the health care provider feels she/he is not able to preserve all interests at stake.” ^{Reference Kälvemark, Höglund and Hansson14} These two later definitions were expanded to reach beyond moral dilemmas; that is, situations where it is (nearly) impossible to do what is morally permissible (or right), including situations that bring about any type of moral challenge. ^{Reference Jameton13,Reference Kälvemark, Höglund and Hansson14,Reference Raines29,Reference Radzvin33} Studies and documents that focused more on the emotional aspect had used the definition developed by Wilkinson: “The psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behavior indicated by that decision.” ^{Reference Wilkinson34} Wilkinson’s definition was narrower than the others by merely including akrasia (weakness of will) as the defining feature of moral distress: that moral distress is only about failing to act on a moral decision.

In Boswell’s study ^{Reference Boswell35} on mental health and moral incongruence in disaster/humanitarian response, moral distress was described as one of the labels of psychological burden of moral compromise using Corley’s definition: “[The] uncomfortable psychological disequilibrium that occurs as a result of unethical performance due to obstacles such as time, supervisory conflict, legal parameters, organizational policy, and hierarchal relationships.” ^{Reference Corley36}

The chapter “Ethics of Healthcare in Disasters and Conflict” in the ICRC’s field guide on Management on Limb Injuries during Disasters and Conflicts described moral distress as: “When one knows the ethically correct action, but feels powerless to take that action,” ³⁷ without referring to any specific definition.

The referenced theories and definitions of moral distress were developed from research on health care in high-resource settings. Four of the authors had developed their own concepts or developed novel theoretical models from their findings. Documents that did not state a definition or theory of moral distress nevertheless described factors that contributed to moral distress and proposed novel tools to address moral challenges. Appendix 3 (available online only) summarizes the concepts of moral distress as described in the included literature.

Decision Making – Moral Uncertainty, Moral Reasoning, and Moral Costs

In the book Humanitarian Action and Ethics, the author described moral distress as derived from decisions related to the micro level; that is, when a health care provider faces challenges in delivering care to individuals. ^{Reference Smith, Ahmed and Smith32} Studies by Hunt and colleagues focused on the concepts of moral uncertainty and difficult moral reasoning coupled to decision making as sources of moral distress. In one study, they explored dilemmas related to decisions on whether to provide care outside of professional competency. Situation analysis and retrospective debriefing were two aspects highlighted that could assist professionals in performing informed ethical decision making. ^{Reference Hunt, Schwartz and Fraser38} In another study by Hunt, participants reported that moral uncertainty and anxiety lead to distress, primarily derived from complex ethical situations. ^{Reference Hunt39} A six-step process was later proposed by Hunt that aimed to give individuals theoretical knowledge to better assess and manage ethical challenges. ^{Reference Hunt40}

Moral cost was another concept that Hunt and colleagues used to describe the result of making decisions or actions that trespass on one’s own moral values. The concept of moral cost is similar to the concept of moral injury. ^{Reference Nordahl28,Reference Boswell35} Hunt, Sinding, and Schwartz described tragic choices as derived from situations of decision making without a “good option,” which leads to moral costs. ^{Reference Hunt, Sinding and Schwartz41}

Clashes with Perceived Ideal or Identity

According to three documents, moral distress is centered around the inability of responders to live up to their professional and personal ideals. Schwartz, Sinding, and Hunt described situations in which responders, health care workers, and agencies in humanitarian work “…do not help as intended, and instead impos[e] harm on patients and/or local staff and health systems” as contributing to moral distress. ^{Reference Schwartz, Sinding and Hunt42} Noutsou suggested that issues related to not being able to maintain professional and personal contribution as intended affect moral distress. ^{Reference Noutsou26} In an article by Schwartz, et al, moral distress among Canadian health care workers was described as: “Ethical challenges which create impacts on both professional and personal identity.” ^{Reference Schwartz, Hunt and Sinding43} High expectations, lack of control, and being unprepared for restructuring priorities were factors contributing to moral distress. ^{Reference Schwartz, Hunt and Sinding43} In their paper of nursing ethics and disaster triage, Wagner and Dahnke suggested that moral distress is developed from situations in disasters in which the nurse “has to ignore the instincts of helping and nurturing patients.” ^{Reference Wagner and Dahnke44}

Organizational Constraints

The decisions and the level of support provided by the responders’ organization influenced the development of moral distress among responders. In a study of the European migration flow, the workers’ levels of moral distress were increased by the organization’s lack of adaption to a new political context, rather than by a lack of resources. ^{Reference Noutsou26} In another document, uneven allocation of aid and lack of information within the organization to effectively deliver response was reported to cause ethical distress among responders. ^{Reference Durocher, Chung, Rochon, Henrys, Olivier and Hunt27} The consequences derived from uneven provision of aid have been testified by humanitarian workers not in direct contact with the affected individuals, and implicates that moral distress is also experienced by non-medical responders. ^{Reference Nordahl28} One study reported that increased geographical distance to the suffering generated emotional detachment and made individuals less prone to moral distress, while individuals directly confronted with the consequences of decision making seemed more prone to both acute and cumulative stress reactions. ^{Reference Nilsson, Sjöberg, Kallenberg and Larsson25} In a study by Gotowiech and Cantor-Graae, worsened stress reactions were reported by health care workers who felt they were silenced and ignored when they reached out for guidance when encountered with moral challenges. Furthermore, the authors implied that increased knowledge of moral distress in organizations is crucial to develop guidance and training frameworks. ^{Reference Gotowiec and Cantor-Graae30} The MSF organization also emphasized the importance of increased knowledge, as fieldworkers have urged better support to manage moral and psychological distress. ^{Reference Biquet, Chang and Salvador31}

Areas of Moral Challenges – Situations that Might Result in Moral Distress

Moral challenges are situations within a disaster response where the responder faces difficulties acting according to their moral values. These situations were also described by Hunt as complex ethical issues. ^{Reference Hunt39} However, these situations result in a stress reaction, labelled as moral stress in two documents, ^{Reference Nilsson, Sjöberg, Kallenberg and Larsson25,Reference Noutsou26} while other documents labeled this stress reaction as moral distress or ethical distress. Suggested indicators of moral distress were how the individuals perceive their moral responsibilities and how the context is interpreted, which determine the severity of the situation when faced by moral challenges. ^{Reference Noutsou26} Contextual challenges were described as external factors that hinder the responder from acting according to what is perceived as right, without trespassing on the autonomy and dignity among patients. ^{Reference Hunt, Schwartz and Fraser38} These decisions must be made by responders during events of mass casualties when it is necessary to select patients who might benefit the most by medical intervention. Choosing between treating individual patients in-need versus focusing on public health care needs are also challenges that health care workers face. ³⁷ An overview of described moral challenges within disaster response and humanitarian contexts is shown in Table 1.

What are the Consequences?

Individuals are guided by their moral values to make decisions in morally challenging situations. ^{Reference Hunt40} Repeated and unaddressed moral distress seems to affect the moral compass and the identity of individuals, which might lead to decreased capacity to follow and act upon personally held moral values. ^{Reference Boswell35} Moral residue was described as lingering moral costs and a cause of strong feelings of anxiety. ^{Reference Hunt, Sinding and Schwartz41} This was also described by Durocher, et al as leading to ethical distress, which was suggested to be highly likely in situations in which all options available to an individual demand something of ethical importance to be surrendered. ^{Reference Durocher, Chung, Rochon, Henrys, Olivier and Hunt27} The MSF research unit (UREPH) had highlighted a pattern of moral distress only becoming visible for the organization when it has resulted in psychological distress. It has also been suggested that repeated and unresolved moral distress leads to moral residue, which further leads to negative psychological consequences. ^{Reference Biquet, Chang and Salvador31} Gotowiec and Cantor-Graae suggested that these psychological consequences lower the responders’ capacity to provide care of high quality. ^{Reference Gotowiec and Cantor-Graae30}

What Makes it Worse? Risk Factors

The risk of moral distress depends on the severity, duration, and a repetitive encounter of morally challenging situations. ^{Reference Nordahl28,Reference Smith, Ahmed and Smith32,Reference Elit, Hunt, Redwood-Campbell, Ranford, Adelson and Schwartz45} Work exhaustion and work dissatisfaction with a lack of control is evidently a destructive factor for moral distress. Furthermore, a lack of knowledge and preparation in managing moral challenges leads to increased risk in developing moral distress. ^{Reference Schwartz, Hunt and Sinding43} Being unprepared for applying an ethical approach that is different from the four traditional principles (autonomy, beneficence, non-maleficent, and justice) was described by Wagner and Dahnke as causing moral distress. ^{Reference Wagner and Dahnke44} Another negative factor mentioned by Gotowiec and Cantor-Graae was the lack of support from co-workers and managers in the team when reaching out for help on ethical issues. ^{Reference Gotowiec and Cantor-Graae30} A lack of formal and informal support during and after the response increased feelings of isolation. Isolation and lack of recognition of moral distress can result in a higher risk of developing negative psychological consequences such as burnout and secondary traumatization. A responder’s altruistic motivations being overrun by the situation at hand is another risk factor for moral distress that has been noted particularly among humanitarian workers. ^{Reference Nordahl28}

How Can Moral Distress be Alleviated? Protective Factors

Resolved moral challenges may lead to confidence and growth within responders. ^{Reference Nordahl28} However, addressing and alleviating moral distress depends on available internal and external resources. External resources can be formal and informal, such as leadership support, support from the team, psychological support, and social support from family, social networks, and peer groups. The availability of internal resources is governed by the level of psychological fitness, workload, psychological distress, and capacity for stress management. ^{Reference Gotowiec and Cantor-Graae30,Reference Boswell35,Reference Hunt39} Allowing a space for ethics in pre-departure training and in the field, as well as in debriefing and long-term support after fieldwork, was therefore emphasized by both MSF and Schwartz, et al. ^{Reference Biquet, Chang and Salvador31,Reference Schwartz, Hunt and Sinding43}